THE LAFERLA MALTA - U.K. COVER
Covers You for treatment in Malta and the UK

 

Policy Definitions
Some of the words used in the policy have special meanings. These words and meanings are set below
1. Accident: A sudden and unexpected injury to the body caused by something external which is violent and visible
2. Acute Medical Condition: A medical condition which lasts a short time, can be treated and quickly cured by medical treatment; or immediately responds to and reduces in intensity to medical treatment; or is not chronic as defined in 5 below.
3. Anniversary Date: Each anniversary of the commencement date which is shown in the Policy Schedule.
4. Beneficiary: The Insured, member or members, dependant or dependants as herein defined as the case may be.
5.  Chronic Medical Condition: A medical condition which fails to respond to medical treatment; or is on-going or consistently recurring; or requires palliative treatment; or requires long periods of medical supervision.
6. Commencement Date: The date on which your insurance cover first starts.
7. Customary Fee: The charge usually made for particular medical services by members of the medical profession of the same, or similar, standing within the same geographical area.
8. Reasonable Fee: The reasonable charge made for the medical services where the Customary Fee cannot be easily determined. A reasonable fee will be calculated by taking into account the complexity of the treatment involved, the degree of professional skill and other relevant factors.
9. Day Care Treatmnent: This is where a Beneficiary is admitted to hospital as registered Day- Care patient and has signed an admission form, occupied a bed, undergone a surgical procedure but not stayed overnight.
10. Dental or Orthodontic: Any disease, illness or injury normally treated by a dentist or orthodontist.
11. Dependant/s: These are the Insured's or Member's husband, wife or "partner" whose details are shown in the Policy Schedule. By "partner" we mean a person to whom the Insured or Member is not legally married but with whom he or she lives and / or own unmarried children including any children living with the Insured or Member as part of the household as shown in the Policy Schedule.
12. Emergency: A sudden and unexpected acute medical condition which, without treatment within 48 hours of onset could result in either death or cause serious bodily impairment.
13.  General Practitioner: A registered medical practitioner in general practice.
14. Hospital: A national hospital. A private hospital or a clinic or a nursing home in Malta or overseas with specialist facilities for treatment and permits for carrying out treatment in terms of the applicable legislation. Any other hospital or other institution which has been approved by the Company.
15. In-patient Treatment: This is where a beneficiary is admitted to hospital and has signed an admission form occupied a bed, undergone a surgical procedure and stayed for one or more nights.
16. Insured: The person named in the Policy Schedule who has the contract of insurance with us.
17. Medical Condition: Any disease, illness or injury except those which we have specifically stated in the Policy not to be covered.
18. Medically Necessary: Treatment that in the opinion of either the Beneficiary's General Practitioner or Specialist is both appropriate and consistent for the medical condition diagnosed which, in accordance with generally accepted medical practice, if not given, would have a serious and adverse effect on the Beneficiary's health.
19. Member/s: Is a person who has joined the Policy as a part of a Group.
20. Out-Patient Treatment: Treatment received from a specialist or under the control of a specialist at a hospital, Specialist consulting room or other placed approved by us when a Beneficiary does not stay overnight or sign an admission form.
21. Palliative: Any medical procedure which is given to temporarily relieve, rather than cure a Medical Condition
22. Physiotherapist: A practitioner who is either State Registered or a Chartered Physiotherapist and a member of the relevant Chartered Society of Physiotherapists and holds the qualification of FCSP, MCSP, SRP or Grad. Dip. Phys. or equivalent.
23. Plan: The medical insurance scheme / healthplan effected by the Insured as specified in the Schedule.
24. Policy Benefits: Any benefit set out in the relative Plan appended to this Policy.
25. Pre-Existing: Any medical condition for which the Beneficiary Medical Condition has received treatment or sought medical advice, and to the best of his knowledge and belief had existed in the two years prior to the commencement date.
26. Private Ambulance: A road vehicle designed to be used as an ambulance and operated by a registered private ambulance service.
27. Qualified Nurse: A qualified nurse whose name is currently on the relative professional register of nursing.
28. Qualified Practitioners: practising Registered Optometrist. A Homeopath who is currently a member of the relative National Homeopathic Association. An Acupuncturist who is currently a member of the relative National Acupuncturists Association and Register. A Reflexologist who is currently a member of the International Institute of Reflexology. An Osteopath who is currently a member of the relative National Council of Registered Osteopaths. A Chiropractor who is currently a member of the relative National Chiropractors Association.
29. Specialist: A medical practitioner who is registered in terms of local requirements and who is or has been a Consultant in a National Hospital and is currently practising in that appointment in the speciality for which the Beneficiary needs treatment; or has a Certificate of Higher Specialist Training or its equivalent given by the Higher Specialist Training Committee of the appropriate Royal College or Faculty in the speciality for which the Beneficiary needs treatment; or is approved by the Company.
30. Schedule of Surgical Procedure: Current list of Surgical Procedures maintained by the Company.
31. Treatment: Any medically necessary surgical or medical procedure, consultation, test or investigation that is given to cure or actively and substantially relieve an acute medical condition, and must be carried out or controlled by a Specialist.
32. We, Us, Our: This means the Company.
33. You, Your: This means the Insured.

 
What is covered and How to claim
In this section we have set out what the Policy covers and how to go about making a claim.
What is covered
The purpose of the Policy is to provide cover for the Customary and Reasonable Fees of recognised treatment which is medically necessary for Acute Medical Conditions. This Policy is not intended to cover experimental or unproven treatment but should such situations arise we will discuss these with Beneficiary's Specialist and decide whether the cost of the proposed treatment is covered. Claims will be paid for those items specified in the Policy Benefits (up to the amounts stated if applicable). If the Policy Benefit does not cover the full cost of treatment, the Beneficiary will be liable to pay the balance.
How to claim
The Beneficiary is advised to give the Company advance notice of any intended treatment. This will give the Company the opportunity to advise the Beneficiary whether costs of the intended treatment are covered under the Policy.
1. The Company may ask the Beneficiary to provide it with such information by the completion of such forms as the Company may require from time to time.
2. For a claim to be payable hereunder, all treatment must be undertaken on the referral of the General Practitioner and given by and under the control of a Specialist, for the purpose of curing an acute medical condition.
3. Payment of the Policy Benefits will be made at the discretion of the Company either to the Insured or the Member, as the case may be, or to the person or company who has provided the Treatment; or in the event of the Insured's or Member's death, as the case may be, the Executors of the relative Estate.
4. To qualify for the Nursing at Home Benefit all Home Nursing must immediately follow a period of in-patient or day-care hospital treatment covered by the Policy; be approved by a Specialist as being Medically Necessary; be for skilled nursing care which would otherwise be provided on an in-patient basis in hospital; be on a full-time basis (i.e. at least 7 hours a day); be given by a qualified nurse under the direction of a Specialist.
5. The Policy Benefits are only payable for eligible treatment received during the period for which the required premium has been paid.
6. Claims can only be considered for payment once the Beneficiary has provided us with all the necessary information and documentation we require.
7. Invoices for treatment will only be considered for payment provided they are the original documents and sent to us within 3 months of the expense being incurred.
8. We are entitled, at our expense, to appoint an independent medical examiner to examine the Beneficiary and to review the claim.
9. The Beneficiary must advise us if any of the Policy Benefits claimed for under the Policy can also be claimed from a third party or under another insurance policy. If the expenses can he claimed under another insurance policy, then we will only pay our proportion of the total amount of those expenses which are eligible for payment under this Policy, If the expenses can be claimed from a third party, then we will pay the Beneficiary, the amount of benefit to which he is entitled. We will then be subrogated to the Beneficiary's right to recover from the third party the amount of benefit we have paid In these circumstances, the Beneficiary must.
1. tell us as soon as reasonably possible that the expenses being claimed for are due to the fault of a third party and provide us with those details which the Company may require; and,
2. do everything we may reasonably and practically require to ensure that the benefits are recovered from the third party.

Exclusions
In this section we have set out what is not covered by the Policy.

We cannot pay claims for any of the following:
1. Treatment for any Medical Condition that we may have specifically excluded from benefits as shown under the heading "Special Terms" in the Policv Schedule or in other relevant documentation.
2. Any pre-existing medical condition. Such pre-existing medical conditions will be covered after two years' continuous insurance cover with us provided that during that two-year period, the Beneficiary has not consulted any doctor for treatment or advice (including check-ups); or taken any medication (including drugs, medicines, special diets or injections) for that Pre-Existmg Medical Condition.

We will only cover pre-existing cardiac or cancer conditions provided at the time when the condition recurs the Beneficiary has been free from treatment, advice or medication for that Medical Condition during the previous five years.
 
3. Fees charged by General Practitioner or anyone acting in that capacity, for providing medical reports.
4. Pregnancy or childbirth (other than for a related abnormal medical condition arising at least ten months after the expectant mother joined the Policy).
5. Infertility, or any form of assisted reproduction.
6. The cost of vaccinations, routine or preventive medical examinations or tests including screening, sight and hearing tests.
7. Fees charged for accommodation and ancillary items, home nursing and rehabilitation which are for or related to social and domestic reasons or are for reasons not related to treatment of an Acute Medical Condition.
8. Treatment received in health hydros, spas, nature cure clinics or in any similar establishments even if they are registered as a hospital.
9. Cosmetic treatment whether or not undertaken for psychological reasons, unless required as the result of an accident.
10. Any Dental or Orthodontic Condition except a procedure listed on the list of Surgical Procedures we publish which must be carried out by an oral and maxillofacial surgeon.
11. Regular or long-term kidney dialysis or end stage renal failure.
12. Treatment arising from a deliberate self-inflicted injury or attempted suicide.
13. Treatment given to relieve any allergic condition or disorder.
14, Treatment arising in any way from alcohol, drug or substance abuse or sexually transmitted diseases.
15. Treatment arising in any way from the Human Immune Deficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS) or any other similar or related condition or syndrome.
16. Treatment arising from nuclear or chemical contamination, war, invasion, act of a foreign enemy, hostilities (whether war be declared or not), civil war, riot, civil disturbance, rebellion, revolution, military force or coup. 
17. Fees charged for aids and appliances including spectacles, contact lenses, hearing aids, wheelchairs, stair lifts and the like.
18. Treatment arising from or related to a sex change.
19, Fees charged where the Beneficiary was admitted to hospital either as an In-patient or on Day-Care basis prior to the date treatment began; or as part of a recuperation process which otherwise could have satisfactorily taken place away from hospital at no expense.
20. Fees charged for prescriptions including drugs, dressings, surgical or dental appliances prescribed on an Out-patient basis or while as an In-patient but for use as an Out-patient.
21. Treatment for congenital abnormalities other than treatment for congenital abnormalities undertaken in an emergency operation carried out on the Beneficiary's child dependant within fourteen days of birth of the child.
22. Fees charged for weight reduction except in cases where it is part of a course of treatment which is medically necessary.
23. Injuries arising from taking part in sporting activities of any kind for which the Beneficiary gets paid or receives a benefit.
24. Treatment given for relieving Chronic Medical Condition or Palliative Treatment of a terminal medical condition.

Payment of Premium
In this section we have set out the conditions for paying the premium.
1. You are responsible for paying all the premium for each person included under the Policy.
2. Premiums are payable to us in Maltese Liri up to 31st December 2007 and in Euros as from 1st January 2008.  Premiums must be paid on the date when they become due. If they are not paid by such date, then We reserve the right to cancel the Policy with effect from the day when the Premium became due.
3. Should any new Members or their Dependants be accepted by us under this Policy, an additional premium will be payable by You. This additional premium will be a pro-rata premium based on the number of months remaining between the date of the acceptance and the renewal date following the said date.
4. Should a Member or his/her Dependant wish to cancel the cover afforded to him hereunder during the policy year a refund of premium will be made by us provided that no claim whether paid or outstanding shall have been made in connection with this Policy during the policy year in which this cover is to be cancelled. Subject to the above the refund of premium will be based on the number of months remaining between the first of the month following the date of cancellation and the next renewal date.

Cancelling the Policy
In this section we have set out the conditions under which we can cancel or change the Policy.
We can cancel or amend the Policy and/or cover immediately if the Beneficiary has provided us with false, wrong or incomplete answers to any information relating to an application for cover, this Policy or claim hereunder, has failed to comply with the terms of the Policy.

Conditions of the Policy
In this section we have set out the general Policy conditions.
1. None of the terms or benefits of the Policy can be changed by any person except by an Endorsement issued by us.
2. The cover provided by this policy shall apply only to judgements or orders that are delivered by or obtained from a Maltese court. Furthermore, the cover shall not apply to a judgement obtained elsewhere whether enforceable in Malta or otherwise.

The policy shall for all effects and purposes be a Maltese Contract and shall be governed by and according to Maltese Law and subject to the exclusive jurisdiction of the Maltese Courts.
 
3. We have the right at any time to alter the Policy, including the terms, premium rates and Policy Benefits.
4. We will not add interest to any money paid or due to be by us paid under the Policy.
5. Where necessary singular words include the plural and plural words the singular and words in the masculine also apply to the feminine.

 
 
Medical Treatment
Cover		 International Medical
Cover		 Malta Private Hospital
Cover		 Malta-UK
Cover

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