2024

Dear Member, June

Welcome to the Alliance Health Options. Thank you for choosing this plan.

We ask you to please read this document as it contains all of the fine print regarding
the terms and conditions of your membership agreement.

Contents of this document:

• Introduction
• Overview of Benefit Levels
• What is Covered
• Waiting Periods 1
• New Enrolments & Renewals
• Benefit Exclusions
• Claims Procedure
• Complaints
• Contact Us
• Glossary
Overview of Benefits
Alliance Health Options is a modular annual health insurance plan for individuals, families and
companies.

The first module is called CORE. This is a compulsory module. This module provides you with
up to US$1,500,000 worth of cover per member per year. This offers you cover for mainly
inpatient treatment, including Hospitalisation, MRI, PET and CT scans, Cancer Treatment,
International Evacuations and Casualty and ER visits. (This is providing you are not being
admitted for an excluded condition*.)

In addition to the CORE module, you can choose a higher level of benefit, the COREPLUS, or
the COMPREHENSIVE or the COMPREHENSIVE PLUS benefits to suit your specific needs.

These benefits are detailed under the “What is Covered?” section of this booklet.
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What Is Covered?
This section will explain what you are covered for in detail. All benefits are subject to the
specific plan which you have joined. All amounts quoted will be in US$.

Where waiting periods are in place, they will refer to a member that has been on a level of
cover that includes cover for that specific benefit for the time period specified. Waiting
periods apply to each member individual, for example, each dependant, and each new
addition to the plan.

Please see your list of benefits for any monetary limits that may apply on your level of cover,
and whether or not the benefit applies to your specific plan.

NOTE: For FAMILY enrolments, BOTH parents and all minor children must be enrolled together
on the same benefit level.

CORE BENEFITS: for all members.

1. In-patient and Day Patient Treatment – Hospitalisation and Surgery

To be eligible for cover under this benefit

▪ Your treatment must be authorised by Alliance Health.
▪ It must be medically necessary for you to occupy a hospital bed for the treatment you
will receive.
▪ Your treatment must be provided by, or overseen by a consultant.
▪ Your room must cost no more than a standard single private room with a private
bathroom. 3
▪ The treating hospital must be a recognised facility.
▪ The length of stay is medically necessary.
▪ The charges must be reasonable and customary to your area of treatment.

Alliance Health reserves the right to request medical reports, quotes and other information
before an authorisation will be given.

You will be covered in hospital for:

a) Intensive Care and Theatre costs, including HCU, CCU and HDU if it is deemed
medically necessary.
b) Hospital Accommodation – up to Private room
c) Nursing Fees, medical expenses and ancillary charges
d) Professional Services including physicians, surgeons, consultants, anaesthetists,
medical practitioners’ fees.
e) Additional private nursing services for members using private hospitals in Zimbabwe
f) Prescribed Medicines, drugs and dressings administered while the member is in
hospital.
g) Surgery, including reconstructive surgery - following an accident or following surgery
for an eligible medical condition. Must be undertaken within 12 months of
accident/illness occurring. To restore natural appearance and function only.
h) Prostheses - Artificial body parts designed to form permanent parts of the member’s
body.
i) Advanced Imaging – MRI, PET and CT scans.
j) Radiology, Ultrasounds and X-Rays
k) Pathology, Diagnostic tests and procedures.
l) Oncology tests, drugs and consultancy fees.
m) Oncology treatment in-hospital including chemotherapy and radiotherapy.
 n) Physiotherapy by a registered physiotherapist, when referred to by a medical
practitioner, Consultant or Specialist.
o) Parental Accommodation for a member under the age of 16 years in the hospital. The
parent must be a member of Alliance Health Options plan.
p) Infant Accommodation – costs relating to a new born infant (up to 18 weeks old) to
accompany its mother (the member) whilst she is receiving treatment as an in-patient
in a hospital.
q) Renal and Peritoneal Dialysis – immediately pre- and post-operatively, in connection
with acute secondary failure when dialysis is part of intensive care, or if it is needed as
a result of chronic and irreversible End Stage Renal Disease or renal failure in both
kidneys provided it is not caused by illness or injury related to alcohol or drug abuse.
r) Blood Transfusions including the costs of blood and blood equivalents, blood products
and transport.
s) Treatment for allergic reactions
t) Psychiatric treatment for up to 30 days (available after 12 months continuous
membership of the plan). Member must be directly under the care of a registered
psychiatrist, whilst admitted in a recognised psychiatric unit. Please refer to the Table
of Benefits for further information.

2. Emergency Medical Services

a) Ambulance Services
▪ Emergency Medical Services ambulance transportation to the nearest facility where
appropriate treatment can be provided.
▪ Transport from the hospital to another medical facility as part of an in-patient stay for
further tests or procedures recommended by your consultant.
▪ Local air ambulance (pre-authorisation is required)
b) International Medical Evacuations
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• When preauthorisation has been given.
• You will be transported to the nearest appropriate medical centre within your area
of cover.
• You may be accompanied by a family member where it is deemed necessary and
safe by the attending EMS crew.
• See further information in the evacuation section of this booklet.

3. Out-Patient Treatment

This is treatment that does not require you to occupy a hospital bed.

a) Advanced Imaging – MRI and PET scans which must be prescribed by a specialist. CT
scans when referred by your specialist consultant or family doctor.
b) Oncology Tests, drugs and consultation fees. This only applies to members undergoing
eligible cancer treatment and not wellness check ups. See further information
regarding the out-patient benefits found in the Table of Benefits.
c) Out-patient chemotherapy and radiotherapy.

4. Optical Benefit

Treatment requiring surgery this will apply to new conditions only. This benefit is for surgery
for diseases that have affected the eye only.
5. Dental Benefit

a) For the emergency treatment in the event of accidental damage to sound natural
teeth. Authorisation must be requested within 7 days of the accident, unless
hospitalised for other more severe injuries which must be seen to before treatment of
teeth can take place. This benefit cannot be used if the damage was caused through
eating.
b) Dental Surgery for the removal of impacted, buried or unerupted teeth, wisdom teeth
removal and retained dental roots. (Available after 12 months continuous membership
on the plan)

6. Trauma Benefit

a) Emergency treatment, including preventative and/or prophylactic ARV and HIV testing
for members who have survived an incident of assault, rape or physical abuse (within
72 hours) need reports from doctors and police?
b) Psychological Counselling for Trauma following an incident of assault, rape, physical
abuse or amputation.
c) Rabies and tetanus vaccinations as well as any antibiotics administered will be covered
in the event of a Trauma only, under this specific benefit.

7. Chronic Medical Conditions

Stabilisation of acute exacerbations/episodes of chronic medical conditions which have

developed after the members join date or covered under MHD benefit conditions and can be
defined as life threatening Acute on Chronic episodes.

8. After Care
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a) Out Patient rehabilitation immediately following hospitalisation. Up to US$20,000 per
membership year.
b) Primary care services of a registered nurse in your home immediately after, or instead
of, in patient or day-patient treatment. Up to US$3500 per membership year.

9. Organ Transplant

Costs of the surgical procedures in performing an organ transplant in respect of the member as
a recipient and not the organ donor. This will cover for transplants for the following organs:
Heart, Heart/lungs, Lungs, Kidney, Kidney/Pancreas, Liver, Allogenic Bone Marrow, Autologous
Bone Marrow.

10. a) Evacuation, Travel, Accommodation and Repatriation Costs

Evacuation costs of moving a member to the nearest appropriate medical facility, within the
area of cover, for the purpose of admission for treatment as an in-patient or day-patient. The
evacuation benefit is restricted to members receiving pre-authorised treatment whilst
admitted to a hospital in a country other than their country of residence

See further information under the Evacuation section of this booklet.

b) Experimental treatment

Members who undergo experimental treatment for life threatening illnesses may not claim the
costs of treatment, or the costs of treating resulting side effects from Alliance Health Options.
However, where such treatment is the members clear preference, and is recommended by the
treating practitioner and is available under a strictly controlled and properly administered legal
trial, then subject to eligibility members may claim benefits from the benefit for
INTERNATIONAL EVACUATION, TRAVEL, ACCOMMODATION AND REPATRIATION benefit

11. Repatriation, Burial or Cremation of Mortal Remains

In the event of a death, the cost of preparation and air transportation of the body, mortal
remains or the ashes of the deceased member, from the place of death to the home country,
or the preparation and local burial or cremation of the mortal remains of the member who
dies outside the home country.

STEP-UP BENEFITS

12. Accident and Emergency Treatment Outside Area of Cover.

a) The cost of emergency medical treatment received in a country or territory outside the
determined geographic area of benefits excluding The Americas.
b) The cost of emergency medical evacuation to the nearest appropriate medical facility
and costs of repatriation of the member back to the home country except when
member has travelled to The Americas.

13. Hospice and Palliative Care – See Benefit Schedule

You will be covered after diagnosis of a terminal condition, when treatment can no longer be
expected to cure your condition, for:

14. Emergency Medical services

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a) Casualty and Emergency Rooms Services for the Treatment of Injuries, Sudden High
Fevers or Other Life-Threatening Conditions.
b) After Hours Consultations at a 24 Clinic

15. Benefit for Out-Patient Treatment

a) Professional services and Specialist Consultations, including Physicians, Surgeons,

Consultants, Anaesthetists.
b) Diagnostic Tests and Procedures (excluding check-ups) – including x-rays and
Pathology.
c) Physiotherapy by a registered physiotherapist, when referred by a medical
practitioner, consultant or specialist.
d) Family Doctor Medical Practitioners fees
e) Prescribed Medicines, Drugs and Dressings (excludes prescribed drugs which may be
available as over the counter purchases)
f) Complimentary Medicines and Treatment by a Registered Therapist
g) Psychiatric Treatment (12 month waiting period)
h) Hormone Replacement Therapy

16. Routine Check-ups - 6 month waiting period applies

a) PAP smears
b) Mammograms and Bone Density Scans
c) Annual Medical Checkups and cancer screening
d) Vaccinations
e) Prostate Checks
17. Maternity Benefits – After 10 months continuous cover on a level of cover that includes
the maternity benefit.

a) Complications of pregnancy and maternity – treatment of a medical condition which

arises during the antenatal stages of a pregnancy, or a medical condition which arises
during childbirth and requires a recognised obstetric procedure, or treatment that is
required as a result of conception or the treatment of a conception. These benefits are
restricted to emergency medical services, casualty and in hospital services.
b) Newborn Benefits- costs related to the assessment and treatment of the new born
babies in hospital at birth or after birth for seven days after birth (available after 10
months continuous membership on the plan, before the baby is born)
c) All in-patient and day patient hospital services relating to maternity (up to 21 days)
d) In-patient obstetric, gynaecological, midwife, paediatrician and other services
required.
e) Outpatient obstetrical expenses including pre-natal and post-natal care.
f) Pregnancy and Childbirth – Costs associated with normal pregnancy and childbirth,
pre- and post-natal check-ups and delivery costs.
g) Outpatient Obstetrical expenses relating to Caesarean Section Deliveries including Pre-
Natal and Post-Natal care.
h) Congenital conditions will be covered to a limit of $ 100,000 per lifetime, if the new
born baby was born to a mother who qualifies for maternity benefit. Limited to the
costs of treatment of conditions that are present at birth and diagnosed before the
new born baby leaves the hospital, and which can be considered medically necessary.

18. Optical Benefits-6 month waiting period (benefit restricted to once every 24 months)

a) Optical Examination
b) Prescription eyeglasses or contact lenses
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19. Dental Benefits-6 month waiting period (benefit restricted to once every 24 months)

a) Dental treatment- including fillings, extractions, root canals, gum treatment

b) Dental X-rays- except for when relating to orthodontic treatment.
c) Crowns and Bridges
d) Consultation and Examination fees
e) Hygienist: cleaning, polishing and scaling
f) Orthodontic treatment or treatment relating to orthodontic will not be covered under
this benefit.

20. Auditory Health Benefits-6 month waiting period (benefit restricted to once every 24
months)

a) Hearing Tests and Examinations

b) Hearing Aid Apparatus

21. Chronic Medical Conditions

a) Stabilising of an acute EMERGENCY exacerbations/episodes of pre-existing chronic

medical conditions (non-MHD) declared on joining (BENEFIT APPLIES TO EMERGENCIES
REQUIRING IMMEDIATE HOSPITALISATION AND APPLIES TO 72 HOURS PER EVENT)
b) Routine Management and treatment including check-ups, diagnostics, treatments and
prescribed medication of chronic medical conditions which developed after the
members join date.
20. Opportunistic Infections Benefit (Additional Benefit Requires Registration)

a) Prophylactic Anti-Retroviral medication for childbirth to prevent mother to child

transmission of HIV/AIDS
b) Treatment, prescribed drugs and medication for the suppression of opportunistic
infections for registered members (subject to 6 months waiting period)
c) Laboratory testing (subject to a 6-month waiting period)

21. Countries and Territories in which Full Benefits Use may be Authorised

▪ Botswana
▪ India
▪ Kenya
▪ Lesotho
▪ Malawi
▪ Mauritius
▪ Mozambique
▪ Namibia
▪ South Africa
▪ Swaziland
▪ Tanzania
▪ Uganda
▪ Zambia
▪ Zimbabwe

21. War and Civil Unrest 8

There are no benefits for treatment resulting from war, invasion, act of foreign enemies,
hostilities (weather declared or not), civil war, rebellion, revolution, insurrection, mutiny,
military or usurped power, riot, strike, lockout, military or popular uprising, civil commotion,
martial law, loot, sack or pillage unless the member sustains bodily injury whilst an innocent
bystander. If the member sustains bodily injury whilst an innocent bystander, then the
member will be covered up to a maximum amount of US$100,000 per member per incident.

22. Travel Cover

Members aged 0-70 will get free travel cover for leisure and tourism activities up to 30 days
per annum. Members traveling within Africa will be covered under the Africa Plan and
members traveling outside region of cover will be covered under the World-wide Standard
Plan. Specific terms and conditions apply.
WAITING PERIODS
The following waiting periods apply to benefit use.

1 = CORE (1) Benefits (In-patient Hospitalisation)

Dental Surgery - 12 month waiting period

Psychiatric Treatment - 12 month waiting period
Chronic Medical Conditions - 6 month waiting period

1+2 = CORE PLUS (1+2) Additional Benefits and Waiting Periods

Dental Surgery - 12 month waiting period

Psychiatric Treatment - 12 month waiting period
Chronic Medical Conditions - 6 month waiting period
Complications of Maternity - 10 month waiting period
New-born Benefits - 10 month waiting period

1+2+3 = COMPREHENSIVE (1+2+3) Additional Benefits and Waiting Periods

Dental Surgery - 12 month waiting period

Psychiatric Treatment - 12 month waiting period
Chronic Medical Conditions - 6 month waiting period

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Complications of Maternity - 10 month waiting period
New-born Benefits - 10 month waiting period
Mammograms and Bone Density Scan – 6 month waiting period
Opportunistic Infections Benefit – 6 month waiting period

1+2+3+4 = COMPREHENSIVE PLUS (1+2+3+4) Additional Benefits and Waiting Periods

Dental Surgery - 12 month waiting period

Psychiatric Treatment - 12 month waiting period
Chronic Medical Conditions - 6 month waiting period
Complications of Maternity - 10 month waiting period
New-born Benefits - 10 month waiting period
Mammograms and Bone Density Scan – 6 month waiting period
Opportunistic Infections Benefit – 6 month waiting period
Optical Benefits - 6 month waiting period
Dental (Hygienist) - 6 month waiting period
Auditory Health - 6 month waiting period
Annual Medical Check Ups - 6 month waiting period
Cancer Screening - 6 month waiting period
Maternity Benefits - 10 month waiting period
Psychiatric Treatment - 12 month waiting period
Joint Replacement- 4 years waiting period

NB: The maternity waiting periods for a spouse do not apply in cases where the father has been a
member for 5 years or more.
NEW ENROLMENTS

New members will be issued with membership cards upon joining. If a new member does not
collect their membership card within 6 months from date of joining, they will be required to
pay for the cards.

Loading/Discount Protocols

New applicants may be loaded for lifestyle choices (such as smoking).

Non-disclosure of Material Facts

If it is understood at any time that an enrolled member has made a false or incomplete
declaration or has failed to accurately disclose his/her medical history then the administrators
of the Alliance Health Options plans reserve the right to waiting periods of up to 48 months,
impose contribution loadings of up to 250%, specifically exclude from benefits specific medical
conditions, disorders or diseases and to recover any or all costs incurred by the fund, or
terminate membership.

RENEWALS
Declaration of Material Facts 10
Members and group administrators are required to declare any changes in lifestyle or group
structure that may result in a material change to their risk profile and/or benefit use. The
administrators of the Alliance Health Options plans reserve the right to vary contribution
loadings at renewal on the basis changes in a member’s risk profile. Members will be issued
with a renewal form to declare any lifestyle changes on renewal.

ENDORSEMENTS
Foreign Treatment Costs

All outpatient treatment outside Zimbabwe is on a pay and claim basis. Members who incur
financial liabilities for the costs of outpatient treatment are personally liable for all costs of
treatment and for all costs of settlement unless a prior written agreement has been made with
the administrators of the Alliance Health Options plans.

CHANGES TO MEMBERSHIP
Death

Should the main plan holder die, his/her dependants will be allowed to continue with their
cover. In order for the membership to be continued, the surviving dependants are required to
complete new Application Forms to facilitate the re-entry of updated data into our systems
and in order to provide a signed agreement of the amended contract between the member
and Alliance Health. Provided there is no break in cover, the new Application Forms will not be
regarded as new enrolments. If the dependants do not wish to continue cover, they must
inform us in writing either by letter, fax or email within four weeks of the main plan holder’s
death.

BENEFIT AND POLICY EXCLUSIONS

Unless specified in the Benefits Schedule/Table of Benefits, or in any written

endorsement, or agreed by Alliance Health in writing, no claim can be made for
compensation or payment for damage or expenses caused by or as a result of the
following:
Abuse of Alcohol or Any Other Substance Whether Controlled or Not: Treatment for alcoholism,
narcotics, drug and substance abuse/dependency or any addictive condition of any kind and any injury
or illness arising from the Insured Person being under the influence of alcohol, drugs or any other
intoxicating substance, including medicines prescribed by a medical Doctor or Consultant. Including
treatment for smoking, or to give up smoking. General treatment of any withdrawal symptoms brought
on by a prior addiction.
Acting Against Medical Advice: Failing to follow instructions or advice given to you by your family
doctor, a general practitioner, specialist or therapist in regard of your diet, your exercise or any other
factors.
Allergic Conditions and Disorders: Desensitising, or neutralising treatment for any allergic condition.
Artificial Life Maintenance: Where the treatment is not likely to result in recovery, or restore the
member to their previous state of health. For example, if the member is in a persistent vegetative state
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or sustains permanent nerve damage
Benefits Not Stated: Costs of any medical treatment or service not listed, or specified in the Benefits
Table.
Congenital Conditions: Claims arising from congenital illnesses, abnormalities or birth defects or
abnormalities. Unless the condition has only manifested after the member’s join date and cannot be
considered a pre-existing condition by normal definition. This will be covered Up to US$10 000 per
lifetime.
Consequent and Subsidiary Costs: Cost that might be levied to the member as charges or fees for
medical reports or other administration.
Contraception: Sterilisation, or reversal of, or any birth control or family planning methods even if
medically necessary. Unless otherwise stated in the Table of Benefits as treatment that is a recognised
contraceptive treatment being used to treat a different health condition where eligible. Please see
benefit #81.
Cosmetic, prophylactic or remedial surgery: removal of fat or other surplus body tissue and any
consequences of such Treatment, weight loss or weight problems/eating disorders, whether or not for
psychological purposes, unless required as a direct result of an accident or surgery for cancer which
occurs during the Period of Insurance.
Costs in Excess of Benefits: Medical Expenses in excess of a limit stated in the Benefit Schedule. Benefit
limits may vary depending on the different plans.
Costs Incurred During Waiting Periods: No payments will be made for benefits where there is a waiting
period until such time as the waiting period is satisfied.
Dental Treatment: Routine and restorative dental treatment. Any orthodontic treatment or treatment
relating to orthodontic procedures will be excluded. For example, X-rays. Gingivitis or treatment of any
gum disease, tooth decay. Unless covered under benefits #68 to 72.
Developmental Problems: treatment for physical development or mental development. Including but
not limited to treatment for delayed development, accelerated development, learning difficulties or
behavioural problems including ADHD, Social Anxiety and Performance Anxiety. Conditions such as
dyslexia or short height will not be covered.
Equipment: Unless otherwise stated in the Table of Benefits the costs for purchase, hire, maintenance
or testing of equipment, or devices including but not limited to: - crutches, wheelchairs, braces,
supports, wheelchairs, diapers, inhalers, EpiPen’s, dentures and glucometers. Please see benefit #83
Experimental Treatment or Unregistered Practice: Treatment and consequences of experimental and
unproven Treatment or drug therapy. Drugs and other medicines purchased without a Physician’s
prescription and routine or preventative medicines. Members who undergo experimental treatment for
life threatening illnesses may not claim the costs of treatment, or the costs of treating resulting side
effects from Alliance Health Options. However, where such treatment is the members’ clear preference,
and is recommended by the treating practitioner and is available under a strictly controlled and properly
administered legal trial, then subject to eligibility members may claim benefits from the benefit for
INTERNATIONAL EVACUATION, TRAVEL, ACCOMMODATION AND REPATRIATION benefit
Foot Care: Treatment of congenital and hereditary conditions including bunions and flat feet.
Fraud: Intentional or fraudulent acts by the Insured Person's part or on behalf of the Insured Person
including non-disclosure of pertinent facts and information relating to pre-existing conditions or risk of
injury/illness not disclosed on joining.
Genetic Testing: Where the tests are to determine the possibility of future development of a disease or
condition or the inheritance of any particular genetic profile
Hazardous Sports or Activities: participation in any professional sports or hazardous sports, hobbies or
activities. Including, but not limited to the following:
▪ Aerial Sport for example sky diving, paragliding etc
▪ Any Sport involving animals, for example Show Jumping, Polo etc 12
▪ Hunting
▪ Motor Sports
▪ Off-Piste Skiing
▪ Racing of any form, other than on foot.
▪ Scuba Diving to a depth greater than 30m, or where an appropriate certificate is not held.
▪ Speed Competitions
▪ Use of Firearms
If you think your profession, sport, or hobby could be defined as dangerous then please contact Alliance
Health for clarification.
Hearing Loss: treatment for hearing loss, or partial hearing loss caused by ageing or congenital condition
or abnormality.
Hereditary Conditions: Treatment of conditions, illness or diseases that have been passed down
through the generations of your family, including any deformities or abnormalities unless otherwise
specified for under the New Born benefit. Please see benefit #62.
HIV and AIDS: treatment and testing for HIV and AIDS. Except where covered under benefits # 77 to 80.
Home Visits: by a medical practitioner, specialist or nurse, unless prior authorisation has been given by
Alliance Health in writing. Please see benefit #33.
Illegal or Criminal Activities: any injury sustained whilst the member is committing an illegal offence, or
helping to commit such an offence.
Infertility treatment: IVF or any treatment to increase fertility or assist with reproduction including
consequences thereof.
Maternity (All Costs Related to Conception): Unless where birth is due after the first 10 months of the
mother’s membership and the benefit is available on the plan (subject to 10 months waiting period from
date of joining). Antenatal classes, midwifery, surrogate parenting and other costs not mentioned in
Benefits #61 to 67.
Mental Health Counselling: Costs for consultations, discussions, group therapy and/or other treatment
by a marriage counsellor, bereavement counsellor, family therapist or life coach unless certified as
medically necessary and provided by a health professional recognised and registered with the
appropriate health professions authority in the country of treatment.
Obesity: as well as any associated treatments such as but not limited to gastric bypass, gastrectomy,
cholecystectomy, gall bladder removal when such treatments are for the purpose of weight control.

Organ Transplant: Costs associated with the location of a replacement organ. Or any costs incurred for
the removal of the organ from the donor, or cost for the organ itself. AHO also will not cover all costs of
administration and transportation of the organ. Costs of removing an organ from the member for
transplantation into another person. Transplants involving mechanical or animal organs. Stem cell
storage, or harvesting, when these cells will be used in possible future illness or disease.
Over the Counter Medication: such as vitamins, or pain tablets, or ointments, or supplements that do
not require a prescription to be purchased.
Performance Enhancement: Any medication or treatment that is related to a desired change or
improvement of performance or behaviour.
Pre-Existing Medical Conditions: Medical Expenses for a Pre-existing Medical Condition or related
condition for which the Insured Person has received or needed treatment, or medication, or sought
advice for the said condition at any time prior to joining Alliance Health Options. Any Pre-existing
Medical Conditions as defined unless otherwise declared on the Application Form and expressly
confirmed acceptance by Alliance Health Options. Except where the member has been given a $5000
lifetime limit for EMERGENCIES relating to specifically mentioned medical conditions. This includes
every condition that the Medical Advisory Board of AHO determines were in existence at or prior to your

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join date. Please see benefit #57.
Pregnancy Terminations: Where non-medically necessary.
Pregnancy, Conception, Childbirth and Post-natal costs whether normal or complicated, including the
transfer of a pregnant woman to hospital to give routine childbirth or air travel when the Insured Person
is more than 28 weeks pregnant, unless cover is provided under the Optional Maternity Benefit as
shown in the Insured Person’s Certificate of Insurance. Please see benefits #61 to 67.
Prophylactic or Preventative Treatment: The costs of surgery, or treatment, or service, or dietary
supplements that are primarily for the prevention of possible ill-health, or to counter the natural effects
of ageing. Malaria prophylaxis and vaccinations (except where stated in the Benefit Table), such as
travel vaccinations, flu vaccinations, epidemics and pandemics, and any other vaccinations
Second Opinion: The administrators of the Alliance Health Options fund may allow or require a second
opinion from a registered medical professional and reserves the right to submit for adjudication
conflicting opinions to the Medical Directors of Alliance Health Options for resolution.
Self-Inflicted Injury and Negligence: Any self-inflicted injury, needless self-exposure to peril (except in
an attempt to save human life), suicide or attempted suicide. If the member is involved, or participates,
in activities or habits against the advice of a medical practitioner, or counsellor, or against health and
safety regulations, where such involvement could lead to injury or harm. Members who require
treatment to remedy the effects of an attempted suicide are restricted to emergency medical services
and casualty for stabilisation up to a maximum cost of $1,500 and for no more than 24 hours.
Septoplasty: Septoplasty and/or Rhinoplasty for the correction of a deviated septum except where such
surgery is required to correct damage which may have occurred in an accident that took place after the
member’s join date.
Sex Changes: any treatment directly or indirectly associated with sex changes or gender reassignments,
or consequences of such treatment unless associated with newly born infants and subject to the
benefits available to members under the New Born benefit. Please see Benefit #61.
Sleep-Related Breathing Disorders: Treatment for snoring, sleep apnoea and other related conditions.
Travel and Accommodation Costs: unless specifically agreed by Alliance Health and only for treatment
received will be in-patient. Unless otherwise covered by your ambulance, or evacuation benefits.
Travel Costs: Travel costs for treatment, unless Pre-Authorised by Alliance Health Options. Travel costs
(evacuation and/or repatriation) where the Insured has travelled against medical advice.
Treatment at and Admissions to Institutional Facilities: Treatment received in any facility that is not
recognised as a hospital
Treatment by a Relative: Treatment performed by a Medical Practitioner or Specialist, who is related to
the Insured Person, unless previously approved by Alliance Health.
Treatment for Eyesight: Normal eye tests. Non-Medical, or natural degeneration of eyesight, or
treatment of such conditions. Unless covered under Benefit #73.

How to Claim

1. Your Claims Checklist

Before you try to submit a claim for costs incurred, please use the checklist below to verify that
you have all of the required information and documentation: -
I have paid for treatment and I would I have not yet received treatment. I
like to claim back all costs would like Alliance Health to contact the
provider of medical services and request
the acceptance of a Guarantee of
Payment so that I do not have to pay and
claim*
I have checked that the treatment was I have checked that this service can be
not for an ineligible condition or an pre-authorised and that the provider of

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excluded condition medical services is willing to accept a
Guarantee of Payment
I have checked the benefits of my plan I have checked that the treatment was not
level and I should be covered for this for an ineligible condition or an excluded
treatment condition
I have checked that the date of I have checked the benefits of my plan
treatment was in the last 3 months level and I should be covered for this
treatment
I have a completed Claim Form, with I have provided Alliance Health with a
every section complete, with both the Medical Report from my doctor
doctor’s and the main member’s
signatures
I have a receipt for every one of the I have provided Alliance Health with the
payments I made names and contact details of the
providers of the treatment
I have provided Alliance Health with
quotations of costs and the dates of the
proposed treatment
I have a Claim Form ready for completion

*Pre-authorisation and guarantees of payment can ONLY be placed for advanced imagery (MRI, CT, PET
and Ultrasound Scans), diagnostics for surgery, for all treatment relating to cancer, for all hospitalisation
and for consultations with specialists. Pre-authorisation is not required for family doctor consultations,
medication or for casualty consultations for life threatening medical emergencies.

Pre-Authorisation
Pre-authorisation means that you must contact Alliance Health before you use any of the
benefits if your plan (except for family doctor consultations, medication or for casualty
consultations for life threatening medical emergencies) – especially if you need us to arrange
payment in advance. This is because we may need to advise you on your benefit limits, or we
may need to arrange pre-payments to some specialists and service providers. Please note that
unauthorised costs of international travel and accommodation are not refundable.
The information required for a quick pre-authorisation is as follows: - (a) we require a medical
report (b) we require a completed claim form (or you can refer to the claim form from the
initial consultation with your family doctor which you may have had) (c) the names and
contact details of your chosen service providers (d) a quotation of costs

PLEASE NOTE: In all cases of hospitalisation your authorisation is limited to a period of

not more than ten days. Authorisations MUST be renewed every ten days. Expenses
arising from unauthorised hospitalisation will be for the member’s account.

1) The Medical Report

The medical report should contain the following information: -

a. The case history
i. When did you, or your dependent, first show symptoms?
ii. When did you first seek advice?
iii. How has the problem been dealt with to date? 15
b. What are the symptoms of the problem?
c. What is the magnitude of the problem (how is it affecting you)?
d. What is the probable cause and diagnosis (or the suspected cause and
the tests that may be required to verify this)?
e. What are the recommendations for treatment?
f. What is the prognosis for the future after you have received treatment?

2) The Service Provider’s Contact Details

a) The names and contact details of the medical professionals and service providers
(radiology / specialists / etc)
b) Contact numbers for the member in the country of treatment
c) Contact email address for the member in the country of treatment

3) The Quotation of Costs

a) The estimated costs of treatment, scans, diagnostics and surgery – including surgeon
charges, anaesthetist charges.
b) The estimated costs, and dates, of international travel supplied by a registered travel
agent
All of this information should be sent together with a copy of the original referral note
to [email protected]

16
What to do in an EMERGENCY

1. Please call an ambulance

2. If you choose not use an ambulance service, please proceed to the Accident &
Emergency or Casualty facility nearest to you. Please remember to take your
membership card with you and proof of your identity. For any serious condition that
may require a hospital admission, please proceed directly to the nearest HOSPITAL
CASUALTY facility.

3. If you have a personal Advisory Agent to assist with claims and benefits use, please call
your agent to notify them. If you do not have a personal Advisory Agent, please notify
Alliance Health on +263 772 126 120 or [email protected]

17
COMPLAINTS

Whilst every effort is made to ensure that your membership to the Alliance Health
Options international health plan is convenient, flexible and valuable to you, we
understand that we may not always meet your expectations of service delivery or that
you may find that you disagree with some of the adjudications and decisions that we
make. We want to ensure that all of our dealings with you are fair and accurate, and
that we are held to account for the quality of our service delivery.

If you feel at any time that we have not achieved this, then please do bring this to our
attention by writing to our Head of Operations. Please note that emails are not
generally useful for this purpose and that a hand written letter (or correspondence
that has been printed out, signed and dated by you the member) is much more
effective. We undertake to respond to your complaint within ten working days.

Any questionable adjudication of claims that are brought to the General Managers
attention in this way are referred to our Medical Advisory Board of qualified, practicing 18
medical professionals. The board will re-examine the claim (often requesting for
further information) and then make their recommendations. In cases whereby we
have failed to provide excellent service to you, the General Manager will review the
incident and where appropriate will initiate appropriate changes to our systems and
procedures to ensure better service delivery.
CONTACT US

Alliance Health
7 Fleetwood Road, Alexandra Park, Harare
2nd Floor, Joina City, CBD, Harare
7 Oak Avenue, Suburbs, Bulawayo
2nd Floor Elephants Walk Shopping Village, 273 Adam Stander Drive, Vic Falls

TELEPHONE: +263 (0) 772 126 120, 772 126 119, 8677000716, 8677020406,

EMAIL: [email protected]

www.alliancehealth.co.zw

19
Glossary of Useful Definitions
Please find below and in this section a list of definitions which is designed to help you
in understanding the wording of your benefits. *

* This document includes excerpts taken from lists of definitions included in previous
documents used by Alliance Health, as well as information readily available on free websites
including personalinsure.about.com, www.nhscareers.nhs.uk, financial-
dictionary.thefreedictionary.com, en.wikipedia.org

A.
Accident
This refers to an unexpected, abrupt or unforeseen external event resulting in bodily injury and/or
trauma.

Accompanying Person
This refers to one designated family member who travels with a member who is being evacuated to the
nearest centre where appropriate treatment can be administered – restricted to a spouse, parent, step
parent, sibling, child, step child, grandchild or guardian.

Accommodation
1 the state or process of adapting or adjusting one thing or set of things to another, the continuous
process or effort of the individual to adapt or adjust to surroundings to maintain a state of homeostasis,
both physiologically and psychologically. 20
2 provision for rest and sleep in a registered establishment

Active Treatment
Treatment of a disease, illness, trauma, injury or other adverse health condition that results in (i)
substantial and effective recovery or (ii) restoration to a previous level of health

Acute Condition
Relating to a disease, trauma, injury or health condition that shows a rapid onset and a short, time
definite, severe course. Acute health problems are characterized by an abrupt beginning with marked
intensity or sharpness, subsiding after a relatively short period. Illnesses that are acute appear quickly
and can be successfully diagnosed and treated.

Administration
The day-to-day administration of membership enrolments, marketing activities, claims adjudication and
payments are carried out by Alliance Health. The adjudication of claims and medical conditions is
carried out in conjunction with the Alliance Health medical advisory board.

Advanced Imaging
Scans used to produce images, including Magnetic Resonance Imaging (MRI), Positron Emission
Tomography (PET) x-ray Computed Tomography (CT), Diagnostic Sonography (Ultrasound), and
Echocardiography but excluding standard x-rays.

Affinity Groups
An affinity group is a group of people who share interests, issues, and a common bond or background,
and offer support for each other. These groups can be formed between friends, or people from the
same community, workplace or organization. For recognition as an affinity group, a group should
present a written constitution or rules of membership for underwriting consideration.
Please be advised of the following restrictions on underwriting for affinity groups: -

(1) The eligibility of each enrolment application is subject to our acceptance

(2) If a group is not a company or a society, we require a copy of the rules of membership (which
should have at least 15 criteria/articles of membership)
(3) If a group has been on cover with a previous PMI, we require copies of the membership
certificates
(4) The group secretary is responsible for the timeous payment of membership subscriptions - which
must be made as lump sum payments either annually, or quarterly or monthly
(5) All applications must be completed and received at least ten working days (two weeks) before
the proposed start date
(6) Additions to the group joining after the join date will need to be accompanied with complete
medical reports or copies of medical files going back 24 months (in English)
(7) Alliance Health reserves the right to implement GROUP RATED membership rates for affinity
groups at renewal based on their claims patterns
(8) We cannot accept affinity groups of less than ten principal members
(9) Married couples cannot apply as two principal members

There are some family groups who wish to be invoiced as a group so that the payment is made by one
person (usually offshore). For example, if I were to join, and my mother were to join, and my aunt, and
my grandmother, and my brother in the UK wanted to pay for our subscriptions - or if we wanted to use
a family trust fund to pay the subscriptions - then it makes sense to group all of the individuals together
so that there is one invoice for payment. The GROUP is registered with Alliance Health and is invoiced
as such. This group would not be eligible for a company discount, as it is not a Company Group and it is
not an Affinity Group. There would be no discount applied.

The formation of "non-genuine" groups that may be made up of arbitrary individuals and families, who
intend to join together to form a group, and who wish to be accepted with a discount is not acceptable
for our underwriting. 21
There is an audit procedure in place to check on the structure (i.e., risk vs discount) of every group on
renewal, and we reserve the right to place any group-on-group risk rated tariffs at renewal. Should we
come across any group that cannot provide copies of the company registration documents, (e.g., CR 14,
ITF 263 in Zimbabwe) or the rules of membership for an affinity group, then any applied discounts will
certainly be immediately removed on renewal.

Agreement
This refers to all of the information contained in this complete document as well as (i) your fully
completed and signed enrolment application form, (ii) your certificate of membership (iii) the table of
benefits (iv) any further endorsements or notations issued by Alliance Health.

Alliance Health
Alliance Health is a private company registered in Zimbabwe, providing administration, marketing and
support services to members of different international health plans and medical aid societies. Alliance
Health is registered with the Ministry of Health and Child Welfare and conforms to all of the
requirements of the Medical Aids Act and the Health Act governing the activities of health care
companies in Zimbabwe.

Alliance Insurance Company is a separate wholly owned Zimbabwean company which is duly licensed
and regulated in terms of the Insurance Act. Commencing operations the 1st of January 2003, Alliance
Insurance Company offers short term insurance and a significant proportion of our products are sold
through intermediaries and brokerage services, who are in essence our strategic partners.

Alliance Health and Alliance Insurance Company continue to be focused on innovative product
development and on delivering high levels of customer service. The strong balance sheets of both
companies are geared to achieve acceptable solvency margins allowing us to pay claims expediently.
The companies also boast a highly skilled and motivated human capital base with a wealth of experience
in insurance and risk management.
Application Form
This term refers to the enrolment application form that you completed and which you signed on behalf
of your dependents listing (i) the details of their identities and relationships to you (ii) all material facts
relating to their medical histories and risk profiles for underwriting and registration (ii) your choice of
plan and associated benefits

Area of Full Benefits

This refers to the territories listed below in which all of listed benefits of membership to the Alliance
Options plans (refer to the Benefits Table) may be used: Botswana, India, Kenya, Lesotho, Malawi,
Mauritius, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe.

Authorisation
Authorisation is the term used to describe the process used to establish and confirm that (i) the costs
related to a member’s treatment can be covered by the benefits available (ii) that the condition
requiring treatment is eligible for benefit (iii) that direct settlement of costs can be negotiated with the
providers of medical services (applies to oncology, evacuations and in-patient treatment). Requests for
written authorisation should be made by the member to Alliance Health, tele: +263 (0) 8677000716/
772 126 120 or by email to [email protected].

Members MUST seek prior approval (i.e., authorization) before being hospitalized for elective treatment
as well as having costly procedures such as CT and MRI scans, chemotherapy & radiotherapy, expensive
medication, etc. Treatment costs that are not approved in advance may only be refunded to members
on a pay and claim basis at 80% of reasonable and customary costs.

At least 2 working days are required to effect an authorization and for requests for Letters of Guarantee
(LOG) to be placed with the treatment providers.

Verbal authorisation (in the case of emergencies) can be obtained by calling the after-hours pre-
authorization numbers: +263 (0) 772 126 120 or +263 (0) 8677000716
22
In order to provide authorization, Alliance Health will require (i) a medical report (ii) a quotation of costs
(iii) the names and contact details of the proposed medical service providers

B.
Benefits
Subject to the information and restrictions shown on the Table of Benefits, members are able benefit
from the costs of consultations and procedures and operations undertaken by medical professionals on
members or their registered dependants for eligible conditions being paid according to what is
understood to be Reasonable and Customary. Where the charges made by provider of medical services
and/or treatment exceed levels that are Reasonable and Customary or where a member or his/her
dependants exceed annual limits, the member is responsible for the resulting shortfall.

Birth Defect
Birth defects are defined as any abnormality or disability arising during pregnancy, or caused during
childbirth or any deformity or congenital anomaly.

Bodily Injury
Defined as an identifiable physical injury from trauma.

Broker
An Insurance Broker is someone who represents you with your insurance transactions, unlike an agent,
who represents the company providing the insurance or membership scheme. In Zimbabwe it is a
requirement for brokers of insurance products to be registered with the Commissioner of Insurance.

Regular face to face meetings with your agent or broker is critical in proper health scheme and/or health
insurance planning. Use the checklist below to make sure you have all the information you might need
to complete the various applications, have a meaningful discussion with your advisor and to make sure
that you are able to select the best option for your requirements.
• The full names, dates of birth and ID numbers of all persons to be enrolled
• Complete medical histories, or records of hospitalisation and medication in the last 5
years
 • Clear job titles and an understanding of which industries/career fields the applicants
work in
• Copies of membership certificates of any previous memberships to any medical aid
society schemes, membership plans or health insurance schemes
• Documents relating to any rejected claims or problems encountered with previous
memberships to any medical aid society schemes, membership plans or health
insurance schemes

C.
Census of Members
This refers to the list of enrolled members updated on a monthly basis. Amendments to the census of
any group or family membership must be provided to Alliance Health before the tenth working day of
the preceding month for adjusted billing.

Certificate of Membership
The Membership Certificate means confirmation of the cover issued by Alliance Health, reflecting the
details of your membership. Your Membership Certificate confirms the level of benefits and the Add-
on’s you have purchased plus your period of cover, your commencement date, your renewal date, your
country of residence, your area of benefits, a schedule of members and any special terms or excess
amounts pertaining to your specific membership.

Chronic
Refers to a medical condition which has at least one of the following characteristics:
• It continues indefinitely and has no known cure
• It recurs or is likely to recur
• Requires palliative treatment (relief/relieving without curing)
• Needs indefinite monitoring and /or treatment
• Requires rehabilitation and /or specialist training
• It requires long term monitoring, consultations, check-ups and examinations
23
• Is caused by bodily changes that cannot be reversed

Claim/Claims
Refers to documentation relating to the costs of professional medical treatment for specific injury,
illness, accident, medical condition or dental condition which has been submitted by a service provider
or by a member for reimbursement.

Close Family Member

This refers to: spouse, parent, step-parent, parent-in-law, brother, brother-in-law, step-brother, sister,
sister-in-law, step-sister, child, step-child, grandchild or guardian.

Commencement Date
This is specific to the date of joining or to any subsequent renewal date pertaining to a specific plan year
as will be specified on a valid Certificate of Membership.

Complementary Medicine and Treatment

Complementary Medicine is the use of natural therapy and medicines to restore and maintain health in
addition to conventional medicine. This includes osteopathic, chiropractic, acupuncture, herbal
medicine, homoeopathy, naturopathy, reflexology, speech therapy, occupational therapy,
anthroposophy and Chinese medicine. Eligible therapeutic interventions are restricted to those that (a)
target the individual disease processes of conditions recognised by the World Health Organisation
International Classification of Diseases or (b) assist in the recovery of injury related trauma.
Practitioners must be suitably qualified and registered with the appropriate, recognised professional
governing body. Alliance Health reserves the right to refer adjudication of claims to the Alliance Health
medical advisory board for assessment against the criteria of the treatment being considered (1)
medically necessary (2) treatment of an acute condition and (3) effective treatment
Complications of Pregnancy
Refers specifically to in-patient or day-patient treatment received for a medical condition that occurs
during the antenatal stage of pregnancy or to a medical condition that occurs during childbirth and
which necessitates a recognised obstetric procedure.

As an illustration we would consider treatment of the following:

- ectopic pregnancy (where the foetus is outside the womb)
- hydatiform mole (abnormal cell growth in the womb)
- retained placenta (afterbirth retained in the womb)
- placenta praevia
- eclampsia (a coma or seizure during pregnancy and following pre-eclampsia)
- diabetes (if you have exclusions because of your past medical history which relate to diabetes, then
you will not be covered for any treatment for diabetes during pregnancy)
- post-partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth)
- miscarriage requiring immediate surgical treatment
- charges for other necessary care which is provided during hospitalisation for pernicious vomiting in
pregnancy

Congenital Abnormality
Refers to any abnormality, deformity, disease, illness or injury which manifests at birth, whether
diagnosed or not.

Consequential Loss
Refers to any cost incurred which may be associated with a claim but is not covered under the Plan.
(e.g., loss of earnings as a result of a medical condition).

Contributions for Membership

All contributions are payable monthly in advance and any member that fails to pay by the 1st of each
month will be suspended and no claims for the beneficiaries will be processed. All contributions
received from members shall be supported with details of any changes i.e., Resignations, new additions, 24
contact details, etc. In the case of any amendments, these must be provided in writing prior to or at the
time of payment.

Country of Residence
Any territory in which you are resident for 90 days or more within a membership year

Critical
Means a medical condition which is unstable and serious for which the outcome cannot be medically
predicted, the prognosis is uncertain and the patient concerned is in danger of dying.

D.
Date of Joining
Unequivocally means the date on which cover for the member and dependants, as shown on the
Certificate of Membership under the Plan, first commenced.

Day-care Treatment
This refer to admission to a hospital, when a member is admitted for treatment and occupies a bed, but
does not remain overnight.

Dental
Dental treatment is excluded except for (i) certain surgical procedures that can only be performed in
hospital by specially trained maxillo-facial surgeons or (ii) covered under the Chronic Disease
Management Program (iii) where such dental benefits are listed on the Table of Benefits under the
member’s plan.

Dependant
The term dependant shall mean and include a registered and duly enrolled member who is: -
a. The legal spouse of another adult main member;
b. A child of such an adult main member, or
c. The child of a member who is a widow or widower; or
 d. The child of a judicially separated or divorced member who has legal custody of such
child; or
e. The child, step-child or adopted child of a member, who is under the age of 18 and
who is unmarried and who is not entitled to benefits from another medical aid
scheme.
f. A member’s child over 18 years of age who, owing to mental or physical defects or
similar cause is not in receipt of a regular remuneration, subject to the discretion
of Alliance Health and on such conditions as it may specify; or
g. On the recommendation of a member’s parents or a dependant’s spouse’s parents
who are not more than 65 years old.

Diagnostics
Diagnostics is the term used to refer to tests that may be conducted to determine the underlying causes
of symptoms of ill health (including x rays, blood tests, pathology, advanced imaging, etc.) The costs of
diagnostic testing can only be eligible for benefits on referral from a medical professional after a
consultation – for an eligible condition.

Direct Billing Arrangement (DBA)

In some cases, the provider of medical services/treatment may prefer to bill us directly. You will then
not be required to submit a claim form and original receipts. However, your medical service provider
will require your signature on a completed claim form as proof that you have received medical
treatment.

Drugs
The costs of medicine and drugs prescribed by a medical practitioner or dentist can be claimed back
from the member’s benefits provided that such medication/substances are not readily available as
‘over-the-counter’ purchases and that the treatment is for an eligible condition. There is no cover for
‘over-the-counter’ medication. The overall limits for medicines and drugs are detailed on the Benefit
Table. Any member that suffers from a chronic ailment (i.e., diabetes, asthma, hypertension, etc,) and
requires a constant supply of medication must register their ailment and medication requirement with 25
Alliance Health.

E.
Emergency
A serious medical condition that occurs without warning (or with only immediate warning) and which
may be life or limb threatening within a period of several hours (up to 12 hours.) Please note that the
on-call personnel staffing ambulance service call centres in Zimbabwe can generally assist a member in
understanding the severity of a sudden medical condition. If in doubt, please call an ambulance or your
family doctor.

Equipment
Any external or internal device that supports, enhances, or otherwise facilitates the use and /or
movement of a damaged limb or organ.

Exclusions
What is covered on your family or individual health insurance plan? What isn't? This can be a very
distressing question for many. Health insurance companies are not immune from the blows to the
economy therefore they have been reviewing their budgets and in doing so the "Exclusions" list in your
health insurance plan has probably become longer.

It is just as important to understand what is not covered as knowing what is covered on your family or
individual health insurance plan. To find out what is not covered take a look at your health insurance
paperwork. If you cannot find it call your provider and they will send you an additional copy. Although
the exclusions can be spread throughout your paperwork, generally you can find a list of exclusions in its
own area usually listed as "Exclusions."

As you are reviewing your health insurance exclusions section, take a look at the size of the list. If your
health plan has a very large exclusions list, they have tried to find everything and incorporate it there.
But, if you find the exclusions list is short, be careful. A short exclusion list usually means other
exclusions are listed throughout your paperwork. After you have read through your whole family or
individual health insurance plan's paperwork and highlighted every exclusion you can find take a look at
the list of common exclusions below to make sure you haven't missed anything.

Typical Health Insurance Plan Exclusions:

1. Treatment for Pre-existing Health Conditions and related complications

2. Routine, Convenience, and Comfort Items: humidifiers, cough syrup,
3. Band-Aids, telephones, TV's, extra pillows...
4. Reconstructive/Cosmetic and/or Sex Change Surgery (Breast reconstruction is usually an
exception and circumcision is commonly being considered cosmetic therefore may no longer be
covered)
5. Home Care or Private Nursing
6. Dental Care, Hearing and/or Vision Aids
7. Elective Abortions
8. Reversals of Vasectomies or Sterilization (Tubes Tied)
9. Learning and/or Behavioural Problems
10. Experimental Treatments or Drugs and Non-Prescription Drugs

To make sure you don't get a bill that you did not expect it is important to know what is excluded. We
have all heard the horror stories behind the $10 hospital pain pill (an over-the-counter aspirin) so how
much do you think an extra pillow in the hospital might cost you?

F.
Family Doctor
Your family doctor is the doctor who you consult first for advice and assistance in dealing with any
health problems. Your family doctor should be registered as a general practitioner, being the first point

26
of contact for most medical services.

Family doctors who are registered as general practitioners provide a complete spectrum of care within
the local community: dealing with problems that often combine physical, psychological and social
components.
They attend patients in surgery and primary care emergency centres if clinically necessary, visit their
homes and will be aware of and take account of physical, psychological and social factors in looking after
their patients.

G.
General Practitioner
A general practitioner (GP) is a medical practitioner who treats acute and chronic illnesses and provides
preventive care and health education for all ages and both sexes. They have particular skills in treating
people with multiple health issues. GPs call on an extensive knowledge of medical conditions to be able
to assess a problem and decide on the appropriate course of action. They know how and when to
intervene, through treatment, prevention and education, to promote the health of their patients and
families.

L.
Loading
Extra money that is paid in addition to the monthly/annual premium in order to cover certain, agreed
pre-existing medical conditions/circumstances or dangerous lifestyle(s).

M.
Material Fact
Refers to statements made as being absolutely true and unbiased (with reference to medical
information).
Medical Advisory Board
A panel of recognised general practitioners who give professional advice when required by Alliance
Health.

Medical History Disregarded

Members joining group underwritten plans can apply for Medical History Disregarded status (referred to
as MHD). Long standing members (i.e., those with over 5 years membership) can also apply for MHD.

This means that standard restrictions regarding exclusions applied to pre-existing health conditions may
be adjusted or waived. With regards to the way in which MHD is implemented, it is always subject to the
material facts declared in the Medical History Declaration and Underwriters acceptance. Alliance Health
reserves the right to refuse MHD cover, apply permanent exclusions or place waiting periods on certain
medical conditions and related medical conditions.

The optional lifetime limitation on cover for certain pre-existing conditions (e.g., $20,000) is a risk
management strategy that may be considered in order to provide protection to both the fund and to
members with certain pre-existing conditions. It may be applicable to cardio-vascular benefits where
members have pre-existing, but well managed, cases of cholesterol and/or hypertension.

Medical Insurance
What is Medical Insurance and what are the differences between membership to a Medical Aid scheme
and a Health Insurance plan?

Medical Aid Health Insurance

Medical aid is provided by a society of members* Health insurance is provided by a company, owned
who pool their monthly contributions to provide a by shareholders, with insurance and reinsurance
fund for health care costs treaties funding the risk of claims

Medical aid is a not-for-profit enterprise Health insurance is a business enterprise, designed 27

to provide a return on investment to shareholders

Medical aid societies are managed by appointed Health insurance companies are managed as
boards (who are appointed by members annually commercial enterprises
and who are usually members themselves)

Medical aid benefits cover the entire spectrum of Health insurance is most cost effective at
medical treatment, from discretionary, low cost, providing benefits for unforeseen, non-
high frequency events to non-discretionary, high discretionary, infrequent, high-cost health care
cost, low frequency events events

Medical aids are (in general) designed to provide Health insurance is (in general) designed to
members with access to health care at all levels provide members with financial protection against
the crippling costs of expensive, sophisticated
health care treatment of unforeseen events – the
costs of which might prove to be catastrophic

Medical aids often have tiered schemes with Health insurance generally provides for tiered
different benefit limits for each scheme, but the schemes with different service benefits at each
same service benefits across all levels level, but with similar or substantial global limits
for each level

Medical aids encourage cost control through the Health insurance may offer the option of
use of standard tariffs, co-payments and particular discounted contributions in return for the member
limits per event accepting excess payments

Medical aids generally do not vary contributions Health insurance does generally charge members
according to individual risk profiles (e.g., age or for additional risk incurred (e.g., correlated to the
profession) member’s age or profession or other risk factor)

Medical aids generally control against fund abuse Health insurance generally controls against fund
through the use of waiting periods abuse through the use of exclusions
*Medical aid societies were originally designed to
be societies of constituent bodies (i.e., societies
of corporate entities/companies) providing
employee health care benefits and were not
designed for individual family membership.

Medical Practitioner
A recognised professional in the field of medical science who is (i) qualified through the successful
completion of study at a medical school listed in the World Directory of Medical Schools by the World
Health Organisation (ii) registered and licenced to practice by the relevant national and/or state
authorities in the country of practice in the pertinent field of the complaint being treated

Medically Necessary
Means treatment that is appropriate for medical reasons, necessitates treatment or intervention or the
mediation of a medical condition which is covered under the terms and conditions of this agreement
and which will result in the member’s state of health being materially improved.

Medical Report
A medical report should contain the following information: -

(1) The case history

a. When did the member first show symptoms?
b. When did the member first seek advice?
c. How has the problem been dealt with to date?
(2) The symptoms of the problem
(3) The magnitude of the problem
(4) The cause and diagnosis (or the suspected cause and the tests that may be required to verify
this)
(5) Recommendations for treatment 28
(6) The prognosis

Why do we ask for a medical report?

We need to have a medical report so that we are able to have enough information to identify all of the
parameters of the particular medical problem. This information is necessary for us to understand the
associated costs and process the claim quickly. Our international underwriters also require detailed
information for audit purposes and in order to assess our risk for re-insurance. The more information
we have, the quicker we can get claims assessed and paid and the more accurate our re-insurance will
be. Accurate re-insurance treaties are essential for us to maintain our membership rates at their current
levels.

Medication
For a substance to be eligible for benefit as MEDICATION it must satisfy the following criteria (unless
otherwise stated in writing from Alliance Health): -
• It must be a substance that is to be used to treat a recognised condition and to bring about an
improvement in the member’s overall health
• It must be a substance that is legally available via a pharmacy prescription in the country in
which it is prescribed and purchased
• The prescribing medical practitioner must be qualified and registered with the appropriate
professional and state authorities in the country of the prescription
• The substance must be appropriately registered with the relevant professional, state and drug
control authorities in the country of the prescription

Moratorium
A moratorium is a period of time during which certain defined occurrences or behaviours (proscribed
circumstances) should or should not take place. If the complete period of time elapses, and none of the
proscribed circumstances have occurred, then the moratorium period is complete. If at any time any of
the proscribed circumstances re-occurs, then the moratorium period starts again from the end of that
event. With regards to health insurance a moratorium refers to a period of time during which a
member should not seek treatment, medical advice, testing or experience symptoms of particular
medical conditions (usually pre-existing health conditions). The moratorium must elapse before claims
for pre-existing conditions may be eligible under the Plan.

N.
Natural Teeth
Means any teeth that are original and organic and are not artificial replacements or implants.

O.
Obesity
Means any member whose body mass index (BMI)is greater than 30.0 whether pre-existing or not.
BMI = mass(kg) / (height)(metres)

Orthodontic
The treatment of problems concerning the position and appearance of the teeth and jaws including oral
cavities.

Out-patient Treatment
Means treatment at a hospital, consulting room, surgery or at an out-patient clinic where a member
does not occupy a bed.

P.
Palliative
Treatment that reduces pain and/or maintains the symptoms of a condition without curing the cause.

Pay and Claim

For all eligible costs of treatment and/or medical services members must pay all costs and then
29
complete a claim form for submission to Alliance Health for processing. The claim will be received,
adjudicated, processed and the costs reimbursed to the main member. The only exceptions to this may
be in cases where the providers of medical services may have agreed to settle the costs directly with
Alliance Health or where the providers have accepted a Letter of Guarantee (LOG) from Alliance Health
or another case manager on behalf of Alliance Health.

Plan
Refers to the contract between you and us, to provide cover in accordance with the Table of Benefits,
general conditions, benefit conditions and benefit exclusions contained within your Plan documents.

Plan Administrator
Mean the person appointed by you, the Plan holder to administrate the member’s group healthcare
plan and to act as the co-ordinator with ourselves.

Plan Year
Means the 12-month period starting from your commencement date as is shown on the valid Certificate
of Membership.

Plan holder
Mean the person or the organisation or company to which we have issued the Plan, and is named on a
valid Certificate of Membership.

Pre-Authorise(d) or Pre-Authorisation
The process via which a member seeks approval/permission from us before undertaking treatment or
incurring costs. Pre-authorisation may be denied or revoked if new information subsequently negates a
claim. Failure to obtain pre-authorisation may result in claim rejection.
 Pre-Existing Health Conditions
A pre-existing health condition is any health condition, complaint, illness or disease that was in evidence
before or at the time of the member’s join date. Such a condition may be characterised by any of the
following:
• The member had experienced signs or symptoms
• The member experienced symptoms
• Testing provided evidence that the condition was in existence
• The member had sought medical advice
• The member had received medical advice, treatment or medication

A pre-existing condition can affect your BENEFIT USE. Although the health plan provider (Alliance
Health) has accepted you and you are paying your membership fees, you may not have coverage for any
care or services related to your pre-existing condition.

For example: Margaret is a 38-year-old woman who works as a legal advisor. She has been suffering
from migraines for three months. She recently decided to join a private health insurance plan that
includes drug coverage in the available benefits. The only affordable health plan she could find had an
exclusion for pre-existing conditions (i.e., in her case for migraines as well as any related and/or
underlying conditions). After joining the plan, she consulted her family doctor concerning the migraines
and was diagnosed with high blood pressure, which is now well controlled on two medications.
However, all of her claims (including doctor visits, check-ups, tests and medications) related to her
migraines and high blood pressure, (and any complications of the condition) are declined. They are
excluded as pre-existing conditions. However, within that first year of coverage, Margaret also got flu
and a urinary tract infection – both of which were completely covered because they were not pre-
existing conditions.
[NOTE: On the Alliance Options plans that include out-patient services, Margaret would still able to
claim casualty and emergency benefits (up to $5,000 in her lifetime) for any cardio-vascular complaints
(like a heart attack that may be related to her pre-existing condition of hypertension) or migraines or
problems related to hypertension.]
Some examples of the most common medications, conditions and resulting excluded medical conditions
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(examples) are listed in the table below for your convenience: -

Condition Typical Medication Excluded from Benefits of Membership

Gout Allopurinol Renal treatment (including kidney failure)
Heartburn Omeprazole Ulcers and digestive tract complaints
Hypertension Atenolol, Enalapril, HCT, Cardio-vascular treatment (including heart attacks
Nifedipine, Losartan, and strokes), Renal treatment (including kidney
Amlodipine failure)
Elevated Atorvastatin, Simvastatin Cardio-vascular treatment (including heart attacks
Cholesterol and strokes)
Osteoporosis Diclofenac, Fosamax, Fractures, muscular/skeletal treatment
Besemax
Depression/Stress Fluoxetine, Sertraline Psychiatric treatment

Preventative Treatment
Refers to treatment intended to stop a condition which does not yet exist or which has no present
symptoms.

Primary Treatment
Means the initial medical care a patient receives from a medical professional (usually a general
practitioner) before referral to a specialist/consultant for further treatment.

Private Room
A private room in a hospital is defined as a room in which the patient is alone in that room.

Professional Sports
Sports played as a paying job, NOT as a hobby, which makes up the principal source of your income.
Psychiatric
Relating to that which affects the mind, emotions or mental function of a person be it organic, traumatic
or reactive in origin.

R.
Reasonable and Customary

This shall refer to the average amount charged in respect of eligible medical services or treatment costs,
as determined by our experience in any particular country or territory

Rehabilitation
A planned programme of treatment in which the convalescent or disabled person progresses towards,
or maintains the maximum degree of physical and psychological independence of which he is capable.

Related condition
Refers to a disease or illness or injury resulting in a medical condition that is caused by a pre-existing
condition or results from the same underlying cause as a pre-existing condition.

Road Ambulance
Refers to a vehicular road ambulance to transport a patient, as required due to an emergency or
medical necessity to the nearest available appropriate hospital.

Routine Health Check

Means any diagnostic test/screening carried out where no medical conditions or symptoms are present.

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Specialist/consultant
Means a medical practitioner who is practicing and holds the following in the country where treatment
is provided:
• A consultant appointment, or
• A recognised certificate of higher specialist training in the field of medicine for which treatment
is being sought.

T.
Therapist
Is either a chiropractor, osteopath, homeopath, acupuncturist or Chinese herbalist who is qualified and
licensed in the country in which treatment is sought.

Treatment
Means any surgical or medical services, including diagnostic tests, that are required to diagnose, relieve
or cure a medical condition.

U.
Underwriting
Underwriting for insurance is the process of identifying and selecting who and what the insurance
company decides to insure. This is based on a risk assessment. It is pretty much the "behind the scenes"
work in an insurance company where they determine who is insured and how much in insurance
premiums, they will charge the insured person. Insurance underwriting also involves choosing who the
insurance company will not insure.
Example:
Jane went to her insurance agent to get a car insurance policy. After she told the insurance agent that
she had driven without a license and insurance for 5 years and was in jail for reckless driving three
times, the insurance agent said that their insurance underwriting department would not insure her
because they feel she is too much of a risk.
Terms and conditions apply
• Errors and omissions
• Rates correct at the time of going to print as per the month indicated. Please request the
latest version of this document from [email protected]
• Terms and conditions are subject to change with notice being given. Date of last revision:
June 2024

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