Health Insurance

Membership
Guide
Your membership guide & policy conditions
1st July 2023

IMPORTANT
You are requested to read this document.
It contains important information about Your Policy.
 Welcome to
Optimum Global
Thank You for choosing Optimum Global. This document is Your
membership guide and forms part of Your policy. It explains what You
are covered for under the benefits of Your plan and together with the
policy Schedule, benefit table and application; forms the agreement
between you and Optimum Global. We have taken every effort to
ensure that all the important information you require is in this
membership guide. However, if You have any other questions you are
recommended to contact Your adviser/intermediary, or visit Our
website. Please keep this guide in a safe place. If You need
another copy you can view and print online at:
[Link]

Contents

Definitions 2
General Conditions 4
Insurance Cover 7
What We cover 8
Making a claim 13
Making a complaint 14
What We do not cover 15
Renewal of Your policy 16

1
Definitions
Certain words that appear in Your membership guide have been defined below. These have
the same meaning wherever they are used in the Policy whether they appear in bold print or
begin with a capital letter.
The Company, We, Our, Us means Optimum Global Limited. Child Dependant coverage is available for the policyholder’s
dependant children up to the nineteenth (19th) birthday, if
Accident means bodily injury caused solely by violent, accidental,
single, or up to their twenty fourth (24th) birthday if single and
external and visible means and not by sickness, disease or gradual
a full time (minimum twelve (12) hours per week) student of an
physical or mental process.
accredited college or university at the time a claim is incurred.
Accidental Dental Treatment is Treatment necessary to Coverage for such dependants continues through the policy’s
restore or replace natural teeth, damaged or lost in a covered next anniversary date.
Accident. To be covered under this policy Accidental Dental
Chronic Condition: A chronic condition is a disease, illness or
Treatment must take place within fourteen (14) days of the date
injury which has one or more of the following characteristics:
of the covered Accident.
• It needs ongoing or long-term monitoring through
Acute Conditions: An acute condition is a disease, illness or
consultations, examinations, check-ups and/or tests.
injury that is likely to respond quickly to treatment which aims to
return You to the state of health You were in immediately before • It needs ongoing or long-term control or relief of symptoms.
suffering the disease, illness or injury, or which leads You to Your
• It requires Your rehabilitation, or for you to be specifically
full recovery.
trained to cope with it.
Annual Deductible means the accumulative total amount
• It continues indefinitely.
of medical expenses incurred by an Insured Person during any
one Policy Year in excess of which the Policy will indemnify or • It has no known cure.
compensate the Insured Person for medical expenses covered by
• It comes back or is likely to come back.
the Policy.
Congenital Condition means any anomalies, including but not
Application Form means the forms You signed to apply for this
limited to inherited conditions, genetic defects and birth defects
Policy from Us, including any written statement, representation
of the Insured Person that are existing prior to or from the time
or document given to The Company which contains information
of birth regardless of the time of discovery and/or the time of
We relied on in issuing this Policy. Written statements on an
physical manifestation of such anomalies or defects.
Application Form by a prospective Insured about the insured
and his or her dependants are used by the Insurer to determine Dependant means the Insured Person’s legal spouse or co-
acceptance of the risk. This includes any medical history, habitant and/or biological or legally adopted children.
questionnaire and other documents provided to or requested by Due Date means the date of commencement or renewal of
the Insurer prior to the issuance of the policy. cover as shown on the Schedule, or the date on which any
Approved Hospital means a Hospital approved by The subsequent annual payment of premium falls due.
Company to provide treatment for which a benefit may be Effective Date The date on which coverage under this policy
payable under the Policy. begins and which is stated in the Policy Schedule, after the policy
Area of Cover means the countries in which the Insured Person is approved by The Company.
will be covered as determined by the relevant option selected. Eligible Person means, in the case of a corporate policy, Your
Assured, You, Your means the entity named as the Assured in full-time and permanent employees at the Policy Commencement
the Policy Schedule in the case of a corporate policy. In the case Date or at any Renewal Date and whom We have agreed in
of an individual/family policy, it means the Insured Person as writing to be eligible to participate in the insurance plan under
shown on the Policy Schedule. this Policy. In the case of an individual/family policy it means You
and any eligible dependants.
Centre of Excellence means a country of our choice in the
geographical region specified in the Benefit Table in which Emergency Medical Complaint means a medical condition
treatment will be provided if in our opinion suitable treatment resulting from an Accident, or any sudden beginning or
for a medical condition which falls outside of the definition worsening of a severe illness that:
of a Serious Medical Condition and is not available in the a. presents an immediate and serious threat to the Insured
Principal Country of Residence. Such treatment is subject to pre- Person’s health and
authorisation.
b. requires immediate medical attention by a Physician.
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 Home Country means the country declared on the Application a. We are informed in writing of any such permanent change* in
Form. The Home Country of the Insured Person’s Dependants will the country where the Insured Person usually lives and
be deemed to be the same Home Country as declared for that
b. We confirm Our agreement to continue insuring the Insured
Insured Person in the Application Form.
Person under this Policy on such terms as We think are
Home Country Cover means insurance cover provided by the appropriate.
Policy in the Insured Person’s Home Country.
* The Insured Person is deemed to make a permanent change in
Hospital means an institution which is legally licensed as a his or her Principal Country of Residence if that Insured Person
medical or surgical hospital in the country in which it is located. It lives or intends to live in the other country for more than six
must be under the constant supervision of a Physician. This does (6) consecutive months.
not include any entity which is primarily a place for alcoholics or
Reasonable and Customary Charges means charges for medical
drug addicts, a nursing, rest or convalescent home or a home for
care which We or Our medical advisers consider to be Reasonable
the aged or any other similar establishment.
and Customary if they are within a general level of charges being
Illness means a physical condition marked by pathological made by other care providers of similar standing in the locality
deviation from the normal healthy state. where the charges are incurred when giving like or comparable
treatment, services or supplies to individuals of the same gender
Injury means unforeseeable damage inflicted to the body caused
and of comparable age for a similar disease or injury.
solely and directly by an Accident.
Schedule means The Schedule to this Policy headed “Policy
In-patient means a person admitted to a Hospital for treatment
Schedule” which sets out key terms such as the name of the
and for which the Hospital makes a daily room and board charge.
Assured, the Insured Persons, the Benefits and the Policy Limits.
It also includes admission of any duration for the purpose of
surgery and any preparation and procedure in connection with Serious Medical Condition means, for the purpose of
the surgery without incurring any room and board charge. interpreting Emergency Medical Evacuation cover, a condition
which, in the opinion of The Company or its authorised
Insured Person means any Eligible Person or Eligible Dependant
representatives, constitutes a serious or life threatening medical
who is covered under this Policy. For the avoidance of doubt, it is
emergency requiring immediate evacuation to obtain urgent
an individual for whom an application has been completed, the
remedial treatment in order to avoid death or serious impairment
premium paid and for whom coverage has been approved by the
to an Insured Person’s immediate or long-term health prospects.
Insurer and commenced.
Unless agreed otherwise by The Company it does not mean
Material Fact means any fact or piece of information which any circumstances in which the Insured Person is capable of
We have asked for during the initial application process or travelling without a medical escort. The seriousness of the
during the renewal, which You should reasonably be expected medical condition will be judged within the context of the
to know. Insured Person’s geographical location and the local availability
of appropriate medical care or facilities.
Medical Condition any disease, illness or injury, including
psychiatric illness. Specialist means a qualified and licensed Physician, possessing
the necessary additional qualifications and expertise to practice as
Physician or Doctor means a person who is legally qualified in
a recognised Specialist of diagnostic techniques, treatment and
medical practice following attendance at a recognised medical
prevention, in a particular field of medicine such as psychiatry,
school, to provide medical treatment and licensed by the
neurology, paediatrics, endocrinology, obstetrics, gynaecology
competent medical authorities of the country in which treatment
and dermatology.
is provided but who should not be the Insured Person or the
relative, sibling, spouse, child or parent of the Insured Person. Terminal Illness means an advanced or rapidly progressing
incurable illness that is expected to result in the death of
Policy Year means a period of 12 months starting from original
the Insured Person within 12 months and this conclusive
inception (start) date for this Policy and each consecutive
diagnosis of the illness is certified by a Specialist and Company
12-month period for which this Policy is renewed.
Medical Adviser.
Pre-Existing Conditions means any injury, illness, condition or
Third Party Administrator (TPA) means a company or
symptom:
organisation that We may contract with to provide local
a. for which treatment, or medication, or advice, or diagnosis administration and claims handling services.
has been sought or received or was foreseeable by You or
Waiting Period(s) means the period(s) of time (specified in the
the Insured Person prior to the commencement of the Policy
Schedule) from the original inception (start) date of the Policy
for the Insured Person concerned, or
during which this Policy does not cover any treatment made
b. which originated or was known to exist by You or the Insured necessary by any cause.
Person prior to the commencement of the Policy whether
or not treatment, or medication, or advice, or diagnosis was
sought or received.
Principal Country of Residence means the country in which
the Insured Person usually lives/works for more than six (6)
consecutive months as stated in the Application Form or any
other country which We are asked to substitute as the Insured
Person’s new Principal Country of Residence so long as:

3
General Conditions
It is an important part of Our contract that You 6. Data Required If this Policy is administered on the named
basis for either individual/family or corporate applications, You
observe the following general conditions:
are required to furnish Us full particulars showing the Insured
1. Geographical Scope This Policy covers the Insured Persons in Person’s name, sex, occupation, identity card number or passport
the Area of Cover as stated in the Policy Schedule on a twenty- number, date of birth, medical plan, Home Country, Principal
four (24) hour basis. Country of Residence, Effective Date, the date of termination of
The Insured Person shall, wherever possible, seek treatment in the insurance coverage and change in benefits. You are required to
specified Area of Cover except for any treatment of an Emergency notify Us in writing within thirty (30) days of any addition of new
Medical Complaint occurring while outside the specified Area of or deletion of Insured Persons under this Policy. We shall charge
Cover for not more than forty-five (45) days per trip. or refund proportionate premium as may be appropriate.

2. Co-ordination of Benefits The Policy will only provide If this Policy is administered on the headcount basis (experience
compensation on a proportionate basis if the Insured Person rated groups), You are required to furnish Us full particulars
has any other insurance in force or is entitled to indemnity from showing the Insured Person’s name, sex, occupation, identity card
any other source in respect of the same Accident, Illness, death number or passport number, date of birth, medical plan, Home
or expense. We have full rights where permitted by law to take Country and Principal Country of Residence and Effective Date of
proceedings in Your or the Insured Person’s name, but at Our insurance coverage by each renewal date.
expense, to recover for Our benefit, the amount of any payment You are required to furnish Us all information and documents
We have made under the Policy. which We may reasonably require with regard to any matters
3. Co-operation We will have no liability under this Policy unless pertaining to this Policy. We will not be liable for any errors or
You or the Insured Person do all of the following: omissions arising directly or indirectly from any errors or
omissions in any information or documents so furnished. Your
a. co-operate fully with Us and Our medical advisers and records, as may in Our opinion have a bearing on the insurance
b. divulge matters which the Insured Person knows or ought to coverage provided under this Policy, will be available for
know as defined by Us inspection by Us at any reasonable time at Your cost.

c. upon Our request sign any document to empower The You are required to give Us immediate notice of any change in
Company to obtain relevant information, at the Insured the nature of Your business and pay any additional premium that
Person’s expense, from any doctor or Hospital or other may be required by Us.
sources. 7a. Renewal for Individual/Family Policies. Your coverage is
4. Material Changes We must be informed immediately in automatically renewed for the next insurance year by payment of
writing of any material change in information or circumstances the renewal premium before the Due Date provided the existing
whether relating to occupation, business or sporting activity plan You have selected for this policy is still available. On the
affecting You or any Insured Person. We reserve the right either renewal date, We may vary the benefits, cover and/or premium
to continue cover for the Insured Person on terms and conditions by giving thirty (30) days advance notice in writing to You.
We consider appropriate because of the material change in 7b. Renewal for Corporate Policies. The Policy is automatically
information or circumstances or to decline to continue cover renewed for a further term of one (1) Policy Period on each
under this Policy. Renewal Date. At each yearly renewal of the Policy, We have
5. Commencement of Coverage All Eligible Persons on the the right to vary the terms and conditions of the Policy by
Policy commencement date, will be covered under the Policy on giving thirty (30) days advance notice in writing to You.
such date, unless notified otherwise by Us. 8. Termination The Policy may be terminated with effect from
If a Dependant is in Hospital confinement on the date any renewal date by either party giving thirty (30) days notice in
which insurance coverage is to be effective, coverage will not writing of Your intention not to renew the Policy.
become effective until the Dependant is discharged. In the The Company can terminate the policy for reasons of
event of a newborn child, coverage will be incepted with effect nondisclosure, fraud or attempted fraud, on the following basis:
from the birth day provided that notification in writing has been
made within thirty (30) days of birth and approved by Us. A copy
of the birth certificate must accompany the application.

4
 Non disclosure: 10. Cancellation You may cancel the Policy with effect from any
renewal date by giving thirty (30) days notice in writing of Your
• Where the non-disclosure is deliberate and reckless, We
intention not to renew the Policy. The cover on all Insured Persons
will be entitled to void the policy and retain the premiums
will cease on the renewal date. We can suspend or cancel the
previously paid.
product with three months notice before the anniversary of the
• Where the non-disclosure is neither deliberate nor reckless, policy offering another similar policy.
We may void the contract, refuse all claims and retain the
11. Premium mode All policies are deemed annual policies and
premiums previously paid if We would not have entered into
premiums are to be annual, unless We authorise another mode
the contract had all material facts been disclosed to Us.
of payment.
• If We would have offered different terms had all material facts
12. Premium Payment Any premium due must be paid in full by
been disclosed to Us, the contract will be treated as if it had
You and actually be received in full by Us within the time frame
been entered into from inception on those different terms. If
stipulated below:
these different terms would have included a higher premium
We reserve the right to collect the additional premium due, or a. Where the premium is payable on an annual basis, premium
reduce claim settlement proportionately. must be received in full by the Policy commencement date. In
the event an invoice is issued after the Policy commencement
Fraud or attempted fraud:
date, premium must be received in full within 14 days of the
 any claim shall in any respect be false or fraudulent or if
If invoice date.
fraudulent means or devices are used by the Insured Person or
b. Where the premium is payable other than on an annual basis:
any Dependant or anyone acting on their behalf to obtain benefit
under this Policy; i. Premium must be received in full by the Policy
commencement date for the first premium of the Policy
• Where You commit any fraud in relation to a claim We will
period. In the event an invoice is issued after the Policy
have no liability to pay the claim and We will be entitled to
commencement date, premium must be received in full
recover from You any claim settlements We have previously
within 14 days of the invoice date.
made on any claim which is later found to be fraudulent.
ii. Premium must be received in full by Us by the agreed
• We may give You notice that Your contract has been
premium Due Dates for subsequent premiums.
terminated with effect from the time of the fraudulent act.
Upon termination We will have no liability for any claim that c. Failure to comply with these premium payment guidelines may
occurs after the fraudulent act. result in the termination of Your policy. Any reinstatement
of Your policy is at Our discretion and may be liable to
• If the contract is terminated premiums are non-refundable at
underwriting conditions.
the discretion of The Company.
With respect to corporate Policies, where You have confirmed
With respect to corporate Policies, if there are three (3) or less
to renew this Policy but have not provided Us with the complete
employees insured as the Insured Persons under this Policy on
data necessary for the renewal of this Policy by the renewal
any Renewal Date, We will reserve the right to terminate this
date, We shall issue a premium invoice stating the estimated
group Policy and offer individual membership with no further
renewal premium to be made within the period stated. In the
underwriting as long as the coverage remains the same. In the
event any premium due is not paid to Us within the premium
event of war (declared or undeclared) or act of war (whether or
payment period stated, We reserve the right to terminate this
not there has been a declaration of war), We reserve the right
Policy and We will be discharged from all liabilities.
to terminate this Policy by notifying You, the date of termination
For the avoidance of doubt, if a premium has not been received
being at Our sole discretion.
by The Company, claims will not be paid (or agreed to be paid).
9. Termination of Insured Person’s Coverage An Insured
13. Refunds If an Insured or The Company cancels the policy
Person’s cover under this Policy shall terminate automatically on
within the agreed timeframe after it has been issued, reinstated
the date any one of the following events first occurs:
or renewed, We may refund the premium on a pro rata basis.
a. the entire Policy is terminated as provided in Clause 8 ofthis
14. Age For the purpose of determining premiums payable, an
section;
Insured Person’s age shall be based on his/her age last birthday. If
b. with respect to corporate applications, on the date the Insured the age of any Insured Person has been misstated, We reserve the
Person resigns, retires or terminates his employment with You; right to amend and change the applicants premium or cancel the
Policy and refund all premiums paid (less any claims already paid).
c. where the Insured Person is a Dependant and he or she is no
longer qualified as a Dependant of the Eligible Person or when 15. Assignment You or the Insured Person will have no rights to
the Eligible Person is no longer insured under this Policy; assign this Policy or any insurance coverage effected under this
Policy.
d. upon request for cancellation by You;
e. non-payment of premium after the premium Due Date as
provided in Clause 12 of this section.
f. non-disclosure of Material facts as defined in Your Application
Form.

5
16. Applicable Law The terms and conditions of this policy
will be governed by and construed, determined and enforced in
accordance with the laws of the Island of Guernsey.
17. The Insurer – Optimum Global Insurance Company
Registered Office: PO Box 549, Town Mills, Rue du Pre,
St Peter Port, Guernsey, GY1 6HS in respect of Optimum Global
Insurance Company Limited.
18. Currency Payment Payment of all claims will be made in the
currency You request on Your claim form unless this is a restricted
currency, in which case payment will be made in the currency in
which this policy is effected. Claim settlements are calculated on
the basis of the exchange rate used by Us on the date the claims
were assessed.
19. Limitation and Exclusion Clause No (re)insurer shall be
deemed to provide cover and no (re)insurer shall be liable to pay
any claim or provide any benefit hereunder to the extent that
the provision of such cover, payment of such claim or provision
of such benefit would expose that (re)insurer to any sanction,
prohibition or restriction under United Nations resolutions or the
trade or economic sanctions, laws or regulations of the European
Union, United Kingdom, Bailiwick of Guernsey or United States
of America.

6
 Insurance Cover
This document, together with Your insurance Schedule and or compensate the Insured Person for medical expenses covered
benefit table, forms Your insurance policy. Your policy is issued by the Policy. In order to claim for any expense in excess of the
by Optimum Global Insurance Company Limited, a Guernsey Deductible, the Insured Person must be able to substantiate that
registered insurer licensed by Guernsey Financial Services the incurred expense said to fall within the Deductible would
Commission. Guernsey is a world-class financial centre renowned have been covered by the Policy if the Deductible were not
for clear regulation. Optimum Global Insurance Company Limited applied.
is provided with reinsurance security for the Optimum Global
Co-insurance means the proportion of eligible medical expenses
Health plans by AXA PPP healthcare Limited. AXA PPP healthcare
which are covered under the insurance.
Limited is part of the AXA Group, a global insurance company with
a long experience in the insurance market of more than 70 years Co-payment means the proportion of eligible medical expenses
providing exclusive insurance services to more than 105 million which are not covered under the insurance and must be borne by
clients in more than 54 countries around the world. the Insured Person.

The AXA Group provide a wide range of products and services that Deductible amounts and co-insurance and the items of cover to
meet the insurance, protection, savings, retirement and financial which they apply are stated on the Schedule and Benefit Table.
planning needs of millions of customers throughout the UK and Deductible amounts and co-insurance contributions are annually
the rest of the world. accumulative for the purpose of this Policy and the order in which
they shall be applied to eligible claims is Deductible amounts first
*source [Link] & [Link]
and co-insurance amounts second.

Extent of cover What You need to do before You have

The Policy will pay up to the limits and sub-limits stated in the treatment
Benefit Table for medical or other covered expenses as defined
and required as a direct result of the Insured Person suffering an You must contact Us when planning In-patient or daycare
Accident, Illness, Death or any other covered event. treatment (This is treatment for which You are admitted to
hospital or clinic even if only for a few hours)
We will pay any benefits due under this Policy either to the
Insured Person or where a Guarantee of Payment has been If the treatment is given as an emergency then You may not
placed to the providers of covered medical, transportation or be able to contact Us beforehand. Do, however, ask someone
other services whose official receipt to pay that benefit will to contact Us as soon as possible (ideally within 24 hours of
discharge Us from the liability We have under the Policy. Only the admission) and make sure that, when you are admitted to
usual Reasonable and Customary Charges in the geographical hospital, the hospital is given Your membership details and proof
area where covered treatment or services are provided will be of identity so that they can contact Us straight away in order that
paid. Satisfactory proof of claim must be submitted in all cases, a Guarantee of Payment may be placed.
and We may appoint independent administrators to settle claims Please note that failure to obtain pre-authorisation for scheduled
on Our behalf. surgery may result in a higher than expected charge for Your
treatment which We may not be able to settle in full. In such case
Limits of Liability You will have to pay the difference.

The Company’s liability is limited in amount to the sub-limits Contact Our 24 hour support line on +44 (0) 1892 772575
which the Benefit Table says applies to each item or type of 24 hours a day 7 days a week.
cover provided. The annual limit per Insured Person stated in Or contact Optimum Global on claims@[Link]
the Benefit Table is the maximum amount recoverable under the (Monday – Friday 9am – 5pm)
Policy as a whole in respect of any one Insured Person during any
one Policy Year. If benefits are properly claimable after the date
of termination or non-renewal of the Policy, the amounts payable What We cover
shall be calculated as if the expenses had been incurred wholly The following benefits are available. Not all of them may apply
during the preceding Policy Year. in respect of Your Policy, so please refer to the Schedule/Benefit
table to determine the cover actually provided to the Insured
Deductible, Co-Insurance & Co-Payment Person concerned.

A Deductible is the amount of a claim which has to be borne by

the Insured Person before the relevant benefits are payable under 1. Hospital & Related Services
this Policy. i. Hospital Treatment & Services
An Annual Aggregate Deductible is the accumulative total All medically necessary treatment and services provided by or on
amount of medical expenses incurred by an Insured Person during the order of a Physician to the Insured Person when admitted as a
any one Policy Year in excess of which the Policy will indemnify registered in-patient to a hospital.

7
Cover includes: iv. Physiotherapy Treatment
• Pre-admission preparation and procedures in connection with If this benefit is listed on you benefit table, We will pay charges
the surgery without incurring any room and board charge. for physiotherapy treatment of an Insured Person which is received
as a registered in-patient at a Hospital. After 10 sessions of
• Hospital accommodation (up to the cost of a standard private
physiotherapy, We will require a medical report to enable us to
class single-bed air conditioned room), Meal charges,
determine eligibility before We will pay for any further sessions.
• General nursing services,
v. Psychiatric Treatment
• Diagnostic, laboratory or other
We will pay for the costs of psychiatric treatment received as
• Medically necessary facilities and services, an in-patient in a psychiatric unit of a Hospital after the Insured
Person has been insured under this Policy for a continuous period
• Physician’s/surgeon’s/anaesthetist’s fees,
of 10 months. All treatment must be administered under the
• Operating theatre charges, direct control of a registered psychiatrist.
• Intensive care unit charges, vi. Day Surgery
• Specialist consultations or visits The cover provided by the Hospital Treatment & Services benefit
• All drugs, dressings or medications prescribed by the treating extends to include Day Surgery and Surgery performed in an
Physician for in-hospital use. outpatient setting. This benefit means all medically necessary
surgical procedures and related treatment provided by or by order
• Prescribed Post Hospital Treatment following an eligible In- of a Physician to the Insured Person at a Hospital which does
hospital admission (up to max 30 days following discharge) not involve an overnight stay. We do not pay for non-surgical
We do not pay for the costs of non-medically necessary goods or procedures and related treatment. (This is subject to pre-
services including (but not limited to) items such as telephone, authorisation see page 12).
television, newspapers, and meals or accommodations of guests. vii. Hospital Accommodation for Accompanying Parent of
Rehabilitation Insured Child

We do cover in-patient rehabilitation for a short period, but there If this benefit is listed on you benefit table, We will pay
are some limits to Our cover. Accommodation charges incurred by one parent sharing the
Hospital room of an Insured child under eighteen (18) years old,
We will cover in-patient rehabilitation for up to 28 days, so long as: where the latter is treated for Illness or Injury at a Hospital, as an
• it is a part of treatment that is covered by Your policy in-patient for a period and the treating Physician has advised in
writing that a parent should remain with the Insured child. This is
• it takes place in a hospital or unit that specialises in rehabilitation paid from the insured child’s policy.
• a medical practitioner who specialises in rehabilitation is viii. Emergency Local Ambulance Services
overseeing Your treatment
The medically necessary transportation of the Insured Person
• We have agreed the costs before You start rehabilitation by road ambulance to a local Hospital. Cover extends to include
• the treatment could not be carried out on an out-patient basis. local transportation of the Insured Person between airports
and/or home and/or Hospitals by taxi or other suitable modes
If you have severe central nervous system damage following of transport for the purpose of receiving Emergency hospital
external trauma or Accident, We will extend this cover to up to treatment covered by the Policy. For the purpose of this clause,
180 days of in-patient rehabilitation. ‘local’ means within the country in which the Insured Person is in
If you need rehabilitation, please contact Us so We can tell you if when he requires the service.
you are covered. ix. Emergency Treatment Outside Area of Cover
ii. Cancer Treatment Cover includes charges for the investigation Charges for an Emergency Medical Complaint occurring during
and active treatment of cancer. This includes surgery, course of short period business or holiday travel, not exceeding forty-five
radiotherapy or course of chemotherapy, alone or in combination, (45) days per trip as stated in the benefit table. We will not
oncology related tests, drugs and Specialist fees for treatment cover any costs for treatment provided in a Hospital unless the
received as an in-patient or out-patient. hospitalisation begins within twenty-four (24) hours after the
By course We mean a course of six cycles of chemotherapy or six Emergency Medical Complaint arose.
weeks of radiotherapy. A ‘cycle’ of chemotherapy is determined by x. Home Nursing following Hospitalisation
the number of sessions for which the drug is licensed. This will be
determined by reference to AXA PPP healthcare’s clinical panel in Following discharge from Hospital, cost of the full-time or part-
the United Kingdom on a case by case basis. time services of a State registered or Government-licensed nurse
in the Insured Person’s home so long as all of the following apply:
iii. Kidney Dialysis Treatment
• it is prescribed by a Physician for the continued treatment of
Charges for treatment of an Insured Person for kidney dialysis, the specific medical condition for which the Insured Person
this includes treatment received as a registered in-patient or as an was hospitalised, and
out-patient at a legally registered dialysis centre.
• is essential for medical, as distinct from domestic, reasons.
Cover is limited to a maximum period of twenty six (26) weeks
in any one Policy Year and in total for any one claim or event.

8
 xi. Hospital Cash Benefit A. Emergency Medical Evacuation & Assistance
If an Insured Person is admitted to Hospital as a nonpaying in- The cover under this Benefit Clause 3A is defined as:
patient, where the treatment received is free of charge and covered
i. Emergency Medical Evacuation
within the terms under this Policy, We will pay the Insured Person a
daily hospital cash benefit for each night the member is hospitalised, We will only pay for evacuation or repatriation arrangements if
up to the sub-limits stated in the benefit Schedule and for a it is prior approved and authorised by Our 24-hour Emergency
maximum of thirty (30) days per disability. Assistance Centre.

xii. Accidental Dental Treatment We will pay in full the Insured Person’s reasonable transportation
costs for him or her to be evacuated for in-patient treatment if
If this benefit is stated on the Benefit Table, We will pay Dental
the treatment he or she needs is covered under the Policy and
Treatment required to restore or replace sound natural teeth lost
is recommended by his or her doctor for medical reasons and is
or damaged in an Accident and for which treatment was received
not available locally. This must be approved in advance by the 24-
following the Accident and as an in-patient admission.
hour Emergency Assistance Centre. The Insured must provide Us
xiii. Chronic Medical Conditions with any information or proof that We may reasonably ask him or
her to support his or her request.
If this benefit is stated on the Benefit Table, We will pay as per i.
Hospital Treatment & Services listed above to the amount detailed This benefit may include moving You to another hospital which
on Your table of Benefit Table for Your selected plan. If this has the necessary medical facilities either in the country where
benefit is not listed as a separate benefit on Your Benefit Table it You are taken ill or in another nearby country (evacuation) or
will be paid as part of 1. Hospital & Related Services (and the sub bringing you back to Your Principal Country of Residence or Your
benefits within) to the associated benefit amount of Your plan. home country (repatriation). The service includes any necessary
treatment administered by the international assistance company
xiii. Congenital Conditions
appointed by Us whilst they are moving You.
If this benefit is stated on the Benefit Table, We will pay as per i.
ii. Compassionate Travel
Hospital Treatment & Services listed above to the amount detailed
on Your table of Benefit Table for Your selected plan. We will pay the expense of the cost of one economy class return
airfare and all ancillary charges (accommodation, food and
transport only) up to the limit as stated in the Benefit Table, for a
2. Organ Transplantation
family member to join an Insured Person who becomes seriously
All medically necessary costs of an operation for the
transplantation of the kidneys, heart, liver, lung or bone marrow ill while travelling alone outside the Home Country or Principal
where the Insured Person is the recipient. We will only pay for Country of Residence and so long as:
the transplant that is deemed necessary due to the consequence • The Insured Person has been or will be hospitalised in a
of an illness that meets the criteria for transplant. We will not Hospital for a period that is more than seven (7) days and with
pay for any transplants performed with non organic organs or Our prior approval
animal organs. We will not pay for any costs associated with
acquiring the organ and We will not pay for the medical expenses • We or Our medical advisers consider it necessary on medical
of the donor. All eligible costs will be covered under this Organ grounds and/or to avoid the need for medical evacuation.
Transplantation benefit without recourse to other benefit limits iii. Return of Minor Children
insured under this Policy.
The expense, up to the cost of economy class one way airfares
and usual ancillary charges, to return children who are left
3. Emergency Medical unattended to the Home Country or Principal Country of
Evacuation & Repatriation Residence as a result of the accompanying adult Insured Person’s
This benefit applies while You are travelling: Accident, Illness, death, hospitalisation or medical evacuation
covered by the Policy.
a. outside the Home Country or Principal Country of Residence
on holiday or business, not exceeding forty-five (45) days per iv. Dispatch of Medicines
trip, and The expense incurred by or on the order of The Company or its
b. within the Home Country or Principal Country of Residence medical advisers to replace essential medical commodities for an
but excluding war zones, countries where the prevailing Insured Person travelling outside the Home Country or Principal
conditions render evacuation and repatriation impractical. Country of Residence in circumstances where such commodities
have been lost or stolen and no suitable replacements or
The Company and its medical advisers reserve the absolute substitutes are available locally.
right to decide if the Insured Person’s medical condition is
sufficiently serious to warrant emergency medical evacuation and/ B. Repatriation
or repatriation as defined in this document as Serious Medical The cover under this Benefit Clause 3B is defined as:
Condition. The Company or its medical advisers shall also decide
i. Repatriation, Travel or Accommodation Expenses
the place to which the Insured Person shall be evacuated and the
means by which the evacuation should be carried out, having We will pay the expense necessarily and unavoidably incurred in
regard to all the assessed facts and circumstances of which The returning the Insured Person to the nearer of the Home Country
Company is aware at the relevant time. or Principal Country of Residence following Emergency Medical
Evacuation provided that such additional costs are medically

9
necessary and approved in advance by Us or Our medical advisers. to take home drugs we will cover drugs related to the admission
This will not be applicable if an Emergency Medical Evacuation for use up to 48 hours following the admission. We will not pay for
is carried out within the Home Country or Principal Country of medication due to be taken after Your cover has ended.
Residence. We will also pay reasonable transportation costs for one
iv. Out-patient Psychiatric Treatment
other person to travel or remain with the Insured Person during
evacuation when this is considered necessary for medical reasons. If this benefit is stated on the Benefit Table, We will pay for out-
We only pay for one repatriation per illness or injury. patient Specialist consultations with a registered psychiatrist, or
by a psychotherapist or psychologist when under the control of
ii. Repatriation or Local Burial of Mortal Remains
a psychiatrist up to the sub-limits stated in the Schedule when
We will pay the expense of preparation and air transportation of the Insured Person has been referred by a Physician. This benefit
the mortal remains of an Insured Person from the place of death is available after the Insured Person has been insured under this
to the Home Country, or the preparation and local burial of the Policy for a continuous period of ten (10) months.
mortal remains of an Insured Person who dies outside the Home
v. Out-patient Laboratory, X-ray and Diagnostic Services
Country. Within the stipulated Policy limit for this benefit, cover
includes the cost of a single, economy class airfare for one family Laboratory, testing, radiographic and medicine procedures, CT, PET
member accompanying the body back to the Home Country. and MRI scans used to diagnose or treat medical conditions. Such
services must be provided by or ordered by a Physician. We will pay
For the purpose of this clause ‘local’ means within the country
up to the maximum limit per year as stated on Your benefit table.
where the Insured Person died.
vi. Prescribed Out-patient Therapies
C. Emergency Medical Advice & Assistance
We pay for treatment by a legally qualified physiotherapist, speech
In emergencies, the Insured Person may contact Our 24-hour
therapist or oculomotor therapist provided the Insured Person has
Emergency Assistance Centre any time for medical advice, and
been referred for such treatment by a Physician. We will pay up to
evaluation from the attending co-ordinator doctor in order to
the maximum limit per year as stated on Your benefit table.
locate suitable medical services anywhere in the world or to
provide referral to Physicians or Hospitals for personal assessment vii. External prostheses and appliances
and/or treatment as medically appropriate. This number can be
The cost of wigs or other temporary head coverings and external
found on the reverse of Your membership card. You understand
prostheses needed during active treatment of cancer; the cost of
and agree for Yourself and for each Insured Person that such
spinal supports, knee braces and pneumatic walking boots if they
telephone conversations cannot establish a diagnosis and must
are a part of a surgical procedure or integral to the treatment of
be considered as advice only. The Emergency Assistance Centre
a condition you are covered for; up to the limits shown in the
will as far as it is reasonably possible facilitate necessary Hospital
benefits table towards the cost of an external prosthesis needed
admissions by confirming the extent of insurance cover, monitoring
following an accident or surgery for a medical condition and
claims procedures and issuing appropriate guarantees in
prescribed hearing aids.
accordance with the payment guarantee condition of this Policy.
viii. Accidental Dental Treatment

4. Out-patient Benefits If this benefit is stated on the Benefit Table, We will pay Dental
Treatment required to restore or replace sound natural teeth lost
If these benefits are stated on the benefit table We will pay for
or damaged in an Accident and for which treatment was received
eligible medically necessary treatment provided to an Insured Person
within fourteen (14) days following the Accident. We will pay
who is not a registered in-patient at a Hospital and defined as:
up to the maximum limit per year. Sound natural teeth means
i. Family Doctor Services and Prescribed Drugs teeth that are free of decay, fillings, gum disease, root canal
If this benefit is stated on the Benefit Table, We will pay for out- treatment and dental implants and which could function normally
patient services provided by a Physician in his or her capacity as a in chewing and speech. The Insured Person will be required to
general practitioner including the cost of prescribed drugs which furnish proof of sound natural teeth, issued and certified by a
are medically necessary up to the maximum limit per year. We registered Dental Practitioner and such benefit is not applicable
will pay up to a maximum supply of three months medication per to dental implants, crowns or dentures.
prescription for any individual claim made. We will not pay for ix. Prescribed Alternative Medicine
medication due to be taken after Your cover has ended.
If this benefit is stated on the Benefit Table, We will pay
ii. Specialist Services for treatment of a specific medical condition by a qualified
If this benefit is stated on the benefit table, We will pay for Out- chiropractor, homeopath, osteopath, acupuncturist, podiatrist/
patient Services provided by or on the order of a Physician who is chiropodist or Chinese medicine physician. We will pay up to the
licensed and practices as a Specialist or Consultant in respect of the maximum limit per year. For the purpose of this clause, ‘qualified’
services rendered up to the maximum limit per year. means the person is fully trained, legally qualified, registered
and licensed to practice in the country in which the treatment is
iii. Drugs Prescribed by Specialists (including take home provided but who should not be the Insured Person or the relative,
drugs following a hospital admission) sibling, spouse, child or parent of the Insured Person.
If this benefit is stated on the benefit table, We will pay for x. Emergency Room Accident & Emergency Services
prescribed drugs up to the maximum limit as stated in the benefit
table. We will pay up to a maximum supply of three months Services provided to the Insured Person as an out-patient in a
medication per prescription for any individual claim made, provided Hospital Emergency Ward immediately following an Emergency
there is more than three months to Your renewal date. In regards Medical Complaint or Accident.

10
 xi. Vaccinations ii. Complications of Maternity and Childbirth
If this benefit is stated on the benefit table, We will reimburse the • We will pay for additional costs incurred for the treatment
cost of vaccinations up to the limits stated on Your benefit table. of medical conditions as a direct result of pregnancy and
This includes childhood vaccinations and HPV vaccine. childbirth complications. As an illustration We would consider
treatment of the following:
xii. Well Being benefit
- C harges for surgery and related medical care for caesarean
If this benefit is stated on the Benefit Table, We will reimburse
section, which is non-elective and medically necessary, when
the cost of the following tests to the stated sub-limits after
a Physician has certified in writing that a natural delivery
the insured Person has been insured under this policy for a
will endanger the life of the Insured Person and/or her
continuous period of twelve (12) months.
Child(ren).
- A nnual faecal occult blood test - ectopic pregnancy (where the foetus is outside the womb)
- Blood tests (full blood count, biochemistry, lipid profile, - hydatiform mole (abnormal cell growth in the womb)
thyroid function test, liver function test, kidney function test) - retained placenta (afterbirth retained in the womb)
- Bone densitometry - placenta praevia
- BRCA1 and BRCA2 genetic test - eclampsia (a coma or seizure during pregnancy and
- Cancer screening following pre-eclampsia)
- Cardiovascular examination (physical examination, - diabetes (if you have exclusions because of Your past
electrocardiogram, blood pressure) medical history which relate to diabetes, then you will not
- Chest X-ray be covered for any treatment for diabetes during pregnancy)
- Diabetic Screen - post-partum haemorrhage (heavy bleeding in the hours and
- ECG days immediately after childbirth)
- Mammogram - miscarriage requiring immediate surgical treatment
- Neurological examination (physical examination) - charges for other necessary care which is provided during
- PAP test hospitalisation for pernicious vomiting in pregnancy
- Physical examination
• 
Newborn Cover
- Urinalysis
- Well child test • Any charges for non-routine medically necessary treatments
of a newborn for the first thirty days following birth.
xiii. Chronic Medical Conditions
We do not cover any treatments for a baby born after taking
If this benefit is stated on the Benefit Table, We will pay as per
any prescription or non-prescription drug or other treatment
4. Out-patient Benefits (and the sub benefits within) listed above
to increase fertility, or as the result of any methods of assisted
to the amount detailed on Your table of Benefit Table for Your
conception, such as IVF where the baby requires treatment in
selected plan. If this benefit is not listed as a separate benefit on
Special Care Baby unit or requires paediatric intensive care.
Your Benefit Table it will be paid as part of 4. Out-patient Benefits
(and the sub benefits within) to the associated benefit amount of
Your plan. 6. Dental Benefit
If this benefit is stated on the Policy Schedule, We will pay for
5. Maternity Benefit dental expenses up to the Sub-Limit stated in the Benefit Table
for routine and restorative dental treatment that You incur.
If this benefit is stated on the Benefit Table, We will pay for
medical expenses up to the limit stated for each pregnancy that a. Routine dental treatments including scaling, polishing, x-rays,
the Insured Person incurs after having been covered under the compound fillings, tooth extractions, gum treatments, surgery
Plan for the whole of the ten (10) months before incurring the for wisdom tooth extractions but only up to the Sub-limit
medical expenses. per person per Policy Year as stated in the Benefit Table and
subject to the Co-insurance as stated.
i. Routine Maternity
b. Restorative dental treatments and prosthesis including surgery
• We will pay for in-patient or out-patient antenatal
for removal of impacted tooth, removal of roots, crowning,
consultations, delivery and post-natal consultations for up to
root canal treatment, bridging, new or repair of upper or
six weeks following birth as detailed in the benefit table, up
lower dentures and implants but only up to the Sub-limit
to the usual amount charged by the medical practitioner for
per person per Policy Year as stated in the Benefit Table and
these services.
subject to the Co-insurance as stated.
• We will pay for routine care and accommodation for Your
baby for up to five days following the birth.
7. Optical Benefits
• Charges for surgery and related medical care for caesarean If this benefit is stated on the Benefit Table We will pay for the
section which is elective and not medically necessary (i.e. following out-patient optical expenses up to the Sub-Limit stated
a natural delivery will not endanger the life of the Insured in the Benefit Table:
Person and/or her Child(ren)) will be covered up to the
customary and reasonable costs of a natural birth at the • Eye examination annually.
treating hospital. • Frames and lenses (including contact lenses) every 2 years.

11
8. Centres of Excellence
If this benefit has been selected as part of your Area of Cover and
in our opinion suitable treatment is not available in the Principal
Country of Residence for treatment for a medical complaint
which is not considered a Serious Medical Condition treatment
can be sought at a Centre of Excellence. Such treatment is
subject to pre-authorisation. The cost of the treatment will be
paid in full within underlying plan limits and sub-limits. This
benefit excludes the costs of travel to, from and within the
treatment country, and excludes out of hospital accommodation
and any ancillary costs in the treatment country.

12
 How to make a claim and claims conditions
The pre-authorisation and payment of all claims / treatment • give Us all supporting medical information (including all
costs will be subject to Our clinical protocols and managed relevant documents and bills) within ninety (90) days after the
care programme. “Managed Care Programme” means a treatment begins or as soon as possible after such information
healthcare delivery arrangement designed to monitor and is reasonably available, whichever is earlier. We will not accept
reduce unnecessary utilisation of services, to contain costs and photocopies of the relevant documents. Scanned copies of
to measure performance while providing accessible, quality and the completed claim form and supporting documents should
effective healthcare including the most effective and efficient be emailed to claims@[Link]. We reserve the
utilisation of benefits available to each insured person. right to request originals if deemed necessary.
We will act in good faith in all Our dealings with You and the • use a new Claim form for each separate claim or course of
Insured Persons. You and the Insured Persons, in turn, must treatment.
ensure that the following are observed:
Failure to observe these claim conditions, without any
1. Notification of Circumstances that may give rise to a Claim reasonable explanation, may invalidate a claim.
If there are circumstances which will or may give rise to a claim 3. Payment of Claims
on this Policy, You or the Insured Person must ensure that the
All claims will be reimbursed using the currency conversion rate
following are adhered to:
as at date of assessment. We will pay claims in Your preferred
• The 24-hour Emergency Medical Assistance Centre We have currency, however if there is a restriction on the preferred
appointed must be informed immediately if the Insured Person currency We reserve the right to make payment in the currency
may require emergency medical evacuation or repatriation of Your policy is administered in.
mortal remains.
4. Payment Guarantees & Direct Settlements
• Before an Insured Person begins treatment as a Hospital
When We are given adequate advance notice of a claim as
in-patient (except in cases of Accident or acute medical
provided in Claims Condition 1, We or the 24-hour Emergency
emergency), the Insured Person must notify the 24-hour
Medical Assistance Centre will give the Insured Person
Emergency Medical Assistance Centre immediately in writing
confirmation of the extent of insurance benefits, monitor claims
of the intention to seek such treatment, with full details of
procedures, issue (wherever reasonably possible) appropriate
the proposed treatment and the names and addresses of the
payment guarantees and/or arrange direct settlement of the bills
Physician and Hospital concerned.
rendered by Hospitals, Physicians or other service providers.
• In cases of Accident or acute medical emergency, written
We will not provide payment guarantees or direct settlements
notification together with reasonably available supporting
if neither We nor the 24-hour Emergency Medical Assistance
medical information must be submitted to Us within forty
Centre is contacted reasonably in advance with all relevant details
eight (48) hours of the event.
as stated in Claim Condition 1.
2. Making a Claim
Covered out-patient services are not subject to payment
If the Insured Person has not telephoned the 24-hour Emergency guarantees or direct settlement and must be paid by the Insured
Medical Assistance Centre and intends to make a claim, he/she Person and reimbursed subsequently under the Policy. If We make
must: any payment under the payment guarantee or direct settlement
when payment should have been made by the Insured Person,
• complete Our Claim form and submit it to Us before or
You shall reimburse the amount(s) paid by Us within thirty (30)
as soon as possible after an Insured Person seeks covered
days of being notified.
Hospital in-patient treatment. A Claim form may be obtained
from Your usual adviser/ intermediary or from Our website 5. Approved Hospitals
[Link]
The Company has made direct billing arrangements with
In respect of Our Claim form: many leading Hospitals and Physicians. Use of other Hospitals
and Physicians will not invalidate a covered claim provided
• the Insured Person or the Insured Person’s legal personal
the notification of claim conditions of the Policy have been
representative must complete all the details in Section A and B
met and furthermore, that The Company’s liability shall not
and sign it. Bank details must be provided on each claim form
exceed the level of charges that would have been made at such
submitted.
Approved Hospitals for providing similar treatment or services.
• the treating Physician or Dentist must complete all questions in The Company reserves the right to make appropriate reductions
Section C, affix his stamp on the Claim form and sign it. to the benefits payable in respect of treatment obtained from
a Physician or Hospital which is not an Approved Hospital if
the charges incurred are not considered to be Reasonable and
Customary.

13
6. Proof of Claim Making A Complaint
Documentation and receipts together with a fully completed If You are dissatisfied with any aspect of Your policy, We want to
Claim form signed by the treating Physician must be submitted to know about it as soon as possible. It is only by receiving feedback
The Company within the time limits defined previously [90 days] that We can improve things if they go wrong.
If, on the balance of medical fact or probability, it is appropriate Please contact Optimum Global in the first instance at:
for The Company to decline a claim by virtue of the Pre-Existing
Tel: +44 (0) 207 917 6247
Conditions exclusion, the Insured Person shall have the right and
[Link]
obligation to produce such medical evidence as The Company
may reasonably require to enable it to reconsider a claim under Email: enquiries@[Link]
the Policy.
A full copy of Our complaints procedure is available to You, please
7. Examinations contact Us using the above details if You would like a copy.
The Company shall have the right and opportunity through its
medical representatives to examine the Insured Person whenever
and as often as it may reasonably require within the duration
of any claim. In addition, The Company shall have the right to
require a post mortem examination, where this is not forbidden
by law.
8. Arbitration
Any difference of medical opinion in connection with the results
of any Accident, Illness, death or expense will be settled between
two medical experts appointed respectively in writing by the two
parties to the dispute. Any difference of opinion between the
two medical experts shall be referred to an umpire, who shall
have been appointed in writing by the two medical experts at the
outset.

14
 What We do not cover
The following treatment items, conditions, weight control medicines, etc. which may be bought over the
counter, with or without prescription, at a local pharmacy or
activities and their related or consequential
similar.
expenses are excluded from the policy and The
Company will not be liable for them: 11. Costs incurred for or related to any kind of bariatric surgery,
regardless of the reason surgery is needed this includes but is not
limited to the fitting of a gastric band or creation of gastric sleeve.
1. The cost of medical reports, completion of claim forms,
administration charges or any reports unless confirmed by Us. 12. The removal of fat or surplus tissue from any part of the body
whether or not it is needed for medical or psychological reasons
2. Pre-Existing Conditions as defined unless otherwise declared (including but not limited to breast reduction).
on the Application Form and expressly confirmed acceptance by
Us. If You have been accepted on an MHD basis this exclusion 13. Any costs relating to orthodontic treatment and related services.
does not apply. 14. Prosthesis, corrective devices and medical appliances which are
3. Treatment which is not medically necessary or which may be not surgically required.
considered a matter of personal choice. 15. Treatment by a family member.
4. Routine medical examinations or check-ups (except when 16. Treatment that is not scientifically recognised by Western
such benefit is covered under the well being benefit), routine eye European or North American standards except as defined and
examinations, any treatment to correct problems of vision such covered under Prescribed Alternative Medicine.
as but not limited to long/short sightedness and astigmatism,
17. All costs relating to cornea, muscular, skeletal or human organ
routine ear examinations, medical certificates, examinations
or tissue transplant from a donor to a recipient and all expenses
for employment or travel, spectacles, contact lenses, cosmetic
directly or indirectly related to organ transplantation (except as
treatments and plastic surgery or tests and treatment as a result
defined under the Organ Transplantation Benefit).
of cosmetic treatments or plastic surgery, all dental treatment or
oral surgery related to teeth (except when such dental benefits 18. Treatment of self-inflicted injury, suicide or attempted suicide,
are being covered under the policy), rest cures and services or or affray; in respect of affray We will only consider claims where
treatment in any home, spa, hydroclinic, sanatorium or long term there is clear evidence in a official police report that the member
care facility even if it is registered as a Hospital. was not the aggressor, abuse of alcohol, drug addiction or
substance abuse (whether or not related to psychiatric disorders)
5. Treatment for developmental delay or behavioural problems in
and sexually transmitted diseases such as but not limited to
children whether physical or psychological or learning difficulties
Chlamydia, genital herpes, HPV, syphilis, gonorrhoea or any
for more than the first 3 months following diagnosis and only once
consequences thereof.
in the members lifetime
19. Treatment related to sexual or gender reassignment or which
6. Test or treatment related to infertility, assisted conception,
arises from or is directly or indirectly made necessary by sexual or
contraception, sterilisation or its reversal, impotence, sexual
gender reassignment.
dysfunction, birth defects, Congenital illnesses unless as part of
newborn benefit or listed as a separate benefit on Your benefit 20. Any treatment or test in connection with Human
table, umbilical blood or stem cell storage or collection, hereditary Immunodefiency Virus (HIV) Acquired Immune Deficiency
conditions or any abortion performed due to psychological or Syndrome (AIDS) or any AIDS related conditions or diseases
social reasons and consequences thereof. unless the Insured Member has been continuously insured under
this Policy for five (5) consecutive years. If the condition is not
7. Pregnancy or childbirth except when such benefits are shown in
pre-existing and has not been contracted within the first five (5)
the Policy Schedule.
years of the Insured Member’s coverage under this Policy, We
8. Any Emergency Medical Evacuation expense: will reimburse up to US$1,000 per Policy Year and maximum
• related to pregnancy or childbirth (except abnormal pregnancy US$10,000 per life time.
or vital complication of pregnancy occurring within the first 21. Treatment which the Insured Person has elected to receive
six (6) months of pregnancy which endangers the life of the outside the Area of Cover except when it is for an Emergency
Insured Person and/or any of her unborn children) Medical Complaint.
• any evacuation expense related to pregnancy or childbirth or 22. Treatment which has not been established as being effective
miscarriage after the first six (6) months of pregnancy. or which is experimental. However, We will pay if, before
9. Cost of drugs prescribed by family doctor or Specialist except treatment begins, it is established that the treatment is recognised
when such benefits are stated in the benefit table. as appropriate by an authoritative medical body and We have
agreed with the medical practitioner what the fees will be.
10. Standard toiletries such as, but not limited to, shampoos, What constitutes experimental treatment will be determined by
soaps, toothpastes, contraceptives, proprietary headache and AXA’s Clinical Panel in the United Kingdom. The panel will base
cold cures, vitamins (even if prescribed), supplements (even if its decision on the recommendations of the with reference to
prescribed), dietary medicines, herbal products, cosmetic creams, other authoritative bodies around the world. The decision of the

15
Clinical Panel will be binding in all cases. It is recommended that 34. We do not cover treatment of injuries that are as a result of
You contact Us before undergoing any treatment which may fall training for or taking part in any sport for which You:
into this category to ensure that it will be covered by Your plan.
• are paid
In respect of Drugs the drug must be used within the terms of its
licence. • receive a grant or sponsorship (We do not count travel costs in
this), or
23. Genetic or screening tests and treatment including preventative
treatment, such as: • are competing for prize money.

preventative mastectomy; or routine preventative examinations We do not cover treatment of injuries that are sustained when
and check-ups (unless noted under the wellbeing benefit and this taking part in the following sports and activities:
is available on your cover) or tests to check whether: you have a
• base jumping
risk of developing a medical condition in the future; or there is a
risk of you passing on a medical condition; tests where the result • cliff diving
of the test wouldn’t change the course of treatment. This might • flying in an unlicensed aircraft
be because the course of eligible treatment for your symptoms will
be the same regardless of the test result or what medical condition • free climbing
has caused them; or preventative treatment or screening tests • scuba diving to a depth of more than 10 metres, or to a depth
that are unproven or where they are used to direct treatment that of more than 30 metres if You hold an appropriate diving
is not established as being effective or is unproven; or any other qualification or You are being instructed by an appropriately
preventative screening or treatment to see if you have a medical qualified diving instructor, for example an instructor recognised
condition if you do not have symptoms. by PADI (Professional Association of Diving Instructors)
24. Second opinions in respect of medical conditions which have • any activity at a height of over 5,000 metres above sea level
already been diagnosed and/or treated at the date such second
opinions are obtained unless considered by Our medical advisers • canyoning
to be reasonable and necessary having regard to the medical facts • skiing off piste, or any other winter sports activity carried
and circumstances. out off piste without an instructor with the appropriate
25. Additional fees billed by a referring Physician for treatment qualifications.
given after the date on which an Insured Person has been referred 35. Costs or treatment after a renewal date (Due Date) arising
to another Physician or Specialist. from Accident, Illness or death occurring during the previous
26. Injury or illness while serving as a full-time member of a Policy Year unless stated otherwise in this Policy or in any written
police or military unit and treatment resulting from participation communication from Us to You.
in war, riot, civil commotion or any illegal act including resultant 36. Costs or benefits payable under any legislation or
imprisonment. corresponding insurance cover relating to occupational death,
27. Injury or illness sustained while the Insured Person has resided Injury, Illness or disease.
outside the pre-defined Area of Cover for more than forty-five (45) 37. Costs arising under any legislation which increases the cost
consecutive days during the Policy Year. of medical treatment and services received by the Insured Person
28. Out-patient services except as defined under the Out-patient above charge levels which would be considered Reasonable and
Benefits. Customary in the absence of such legislation.

29. Hospital in-patient treatment if the Insured Person could have 38. The cost of transporting an Insured Person by means of
been properly treated for the condition as an out-patient. This Your own or leased watercraft or aircraft or the cost of medical
includes rehabilitation. treatment given by the following parties unless We agree in
writing to meet such costs:
30. We will only cover hormone replacement therapy (HRT) that
is required following a medical intervention. We will pay for the • Your personnel or at Your medical facilities
medical practitioner’s consultations and the cost of HRT implants, • by a third party under a contract between that third party and
patches or tablets for a maximum of 18 months following the You.
intervention. Patches and tablets are subject to Your out-patient
drugs and dressings limit. 39. Costs arising out of any litigation or dispute between the
Insured Person and any medical person or establishment from
31. We do not cover investigations (including diagnosing hair loss whom treatment has been sought or given, or any other costs
type), management or advice for, or treatment for hair loss. We not directly and specifically related to the payment of the medical
will only provide cover for the investigation and treatment of an expenses covered by the Policy.
underlying medical condition.
40. Any loss or damage, cost or expense of whatever nature
32. Travel costs in respect of trips made specifically for the directly or indirectly caused by, resulting from or in connection
purpose of obtaining medical treatment unless in the course of with any of the following even though some other cause or event
an approved Emergency Medical Evacuation, and all Emergency may contribute at the same time or in any other sequence to the
Medical Evacuation costs which are not approved in advance by loss:
Us or Our appointed 24-hour Emergency Assistance Centre.
a. ionising radiation or contamination by radioactivity from any
33. Hotel or non-Hospital accommodation costs except as nuclear fuel or from any nuclear waste from the combustion
provided for in the Policy. of nuclear fuel

16
 b. the radioactive, toxic, explosive or other hazardous or We don’t cover any ATMPS/CGTPs/RMATs that aren’t on the list
contaminating properties of any nuclear installation, reactor or at the time you need the treatment, including any associated
other nuclear assembly or nuclear component hospital or specialist costs. The list is subject to change so you
should always check and call us before you start any treatment.
c. any weapon of war employing atomic or nuclear fission and/or
fusion or other like reaction of radioactive force or matter. 43. Evacuations involving moving you from a ship, oil-rig platform
or similar off-shore location.
41. Death, disability, loss, damage, destruction, any legal
liabilities, cost or expense including consequential loss of every
type which is, directly or indirectly caused by, resulting from or in Renewal of Your Policy
connection with any of the following even though some other Your Policy will remain in force for a period of 12 months
cause or event may contribute at the same time or in any other from the commencement date of Your Policy, provided that all
sequence to the loss unless incurred as an innocent bystander premiums due have been paid and that the Policy has not been
and relevant benefits detailed on the Table of Benefits. terminated under Clause 10 of the General Conditions.
a. war, invasion, acts of foreign enemies, hostilities or warlike As the anniversary of Your Policy approaches, We will write
operations (whether war is declared or not), active involvement to You with the terms of the next period of coverage and the
in criminal activity, civil war, rebellion, revolution, insurrection, premiums due. If it is necessary to make changes to Your Policy,
civil commotion assuming the proportions of or amounting to they will only apply from Your renewal date.
an uprising, military or usurped power; or
b. any act of terrorism including but not limited to:
i. the use or threat of force, violence and/or
ii. harm or damage to life or to property (or the threat
of such harm or damage) including, but not limited to,
nuclear radiation and/or contamination by chemical and/or
biological agents, by any person(s) or group(s) of persons,
committed for political, religious, ideological or similar
purposes, express or otherwise, and/or to put the public or
any section of the public in fear; or
iii. any action taken in controlling, preventing, suppressing
or in any way relating to (a) or (b) above. If We say that
because of this exclusion, any loss, damage, cost or
expense is not covered by this Policy the burden is on You
to prove otherwise.
42. Advanced therapies
There are a complex set of advanced therapies, including gene
therapies and CAR-T treatment for cancer. They are known by
different names across the world, for example Advanced therapy
medicinal products (ATMPs), Cellular and gene therapy products
(CGTPs) or Regenerative medicine advanced therapy (RMAT).
We only cover a small number of ATMPS/CGTPs/RMATS under
your policy. You must call us before you start your treatment to
make sure its covered.
Therapy name Where licenced and used within the terms of that
licence published and in operation on 01 April 2023 we cover for:
Yescarta Diffuse large B-cell lymphoma (DLBLC) and primary
mediastinal large B-cell lymphoma (PMBCL) in adults
Kymriah B-cell acute lymphoblastic leukaemia (ALL) in children
and young adults and diffuse large B-cell lymphoma (DLBLC) in
adults
Tecartus Mantle cell lymphoma (MCL) in adults
Abecma Multiple myeloma in adults
Imlygic Malignant melanoma (a skin cancer) in adults
Alofisel Complex perianal fistula problems in Crohn’s disease in
adults
Holocar Limbal stem cell deficiency in adults following physical or
chemical burns of the eye

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