selections membership guide
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Taking good care
of your peoplewherever they are
Bupa International Selections Egypt Plan
Membership Guide
From 1 January 2011
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This Membership Guide contains the rules and benets ofyour
Bupa International Selections Egypt plan, and other important
information. You also need to check your Membership
Certicate for any personal exclusions that you may have.
Introduction
Your International Selections Egypt plan is administered by Bupa International on behalf of
your insurer, Bupa Egypt Insurance.
Your insurer can be contacted at:
Bupa Egypt Insurance
48 El Thawra Street
Dokki
Giza
Egypt
or you can call the Service Advisor number (from inside Egypt): 16816
Telephone: +20 23762 8685, or Fax: +20 23762 8684.
Ifyou would like to ask any questions about anything that you read here, please contact the
Bupa International customer services helpline. Our contact details are opposite, and are
repeated on each page.
Important
Please keep this Membership Guide
in a safe place. You can download an
updated version at any time from our
MembersWorld website or contact us
to request a new copy.
Bold words
Words in bold have particular meanings
in this Membership Guide. Please check
their definition in the Glossary before
you read on.
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Contact us
* Please note that we cannot guarantee the security of email as a method of communication.
Some companies do monitor email trafc, so please bear this in mind when sending us condential information.
** MembersWorld may not track claims in the USA as we use a third party here.
Bupa Egypt Customer Sevices:Email: egyptcustserv@bupa-intl.com* Web: www.bupa-intl.com
Tel: +20 23762 8685 Fax: +20 23762 8684
Tel from inside Egypt: 16816
General Enquiries:
Your Bupa International customer services helpline
z open 24 hours a day, 365 days a year
z membership and payment queries
z claims information
Email: info@bupa-intl.com* Web: www.bupa-intl.com
Tel: +44 (0) 1273 323 563 Fax: +44 (0) 1273 820 517
Medical Enquiries:
Pre-authorisation and Healthline
z open 24 hours a day, 365 days a year
z check cover and pre-authorise treatment
z medical advice and information
z nd local medical facilities
z medical referrals
z embassy and visa information
z interpreter referral service
Tel: +44 (0) 1273 333 911 Fax: +44 (0) 1273 866 301
MembersWorld:
www.bupa-intl.com/membersworld
z view membership status z track claims online **
z update personal details z access hospital directory
z webchat zmuch more
z download claim forms
Any correspondence, including your claims, should be sent to the following address:
Bupa Egypt Insurance, 48 El Thawra Street, Dokki, Giza, Egypt
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Contents1. How to use your Bupa International Selection Egypt plan
2. What is covered?
3. What is not covered?
4. Assistance Cover
5. Pre-authorisation
6. Making a claim
7. Your membership
8. Making a complaint
9. Glossary
10. Medical words and phrases
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*Please note: due to the cost oftreatment in the USA, members must pre-authorise all treatment. This is to make sure that the
treatment you wish to have is eligible and so that we can advise you, in advance, ifyou will need to contribute to your own
treatment costs.6
Step 1: Where to get treatment
As long as it is covered by your plan, you
can have yourtreatment at any recognised
hospital or clinic. Ifyou dont know where to
go, please contact our Healthline service for
help and advice.
Participating hospitals
To help you nd a facility, we have also
developed a global network of over 7,500
medical centres, called participating hospitals
and clinics. The list is updated regularly, so
please visit www.bupa-intl.com for the latest
information. We can normally arrange direct
settlement with these facilities (see Step 3
below).
Getting treatment in the USA
You must call our Service Partner on800 554 9299 (from inside the US), or
+1 800 554 9299 (from outside the US)
to arrange any treatment in the USA*.
Step 2: Contact Bupa International
Ifyou know that you may need treatment,
please contact us rst. This gives us the chance
to check your cover, and to make sure that
we can give you the support ofour globalnetworks, our knowledge and our experience.
Pre-authorising in-patient treatment
and day-case treatment
You must contact us whenever possible
before in-patient or day-case treatment,
for pre-authorisation. This means that we can
conrm to you and to yourhospital that your
treatment will be covered under your plan.
Pre-authorisation puts us directly in touch
with yourhospital, so that we can look after
the details while you concentrate on getting
well. Section 5 contains all of the rules and
information about pre-authorisation.
When you contact us, please have your
membership number ready. We will ask
some or all of the following questions:
z what condition are you suffering from?
z
when did your symptoms rst begin?z when did you rst see yourfamily doctor
about them?
z what treatment has been recommended?
z on what date will you receive the
treatment?
z what is the name ofyourconsultant?
z where will your proposed treatment take
place?
z how long will you need to stay in hospital?
1
How to use your
Bupa InternationalSelections Egypt plan
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Ifwe can pre-authorise yourtreatment, we
will send a pre-authorisation statement that will
also act as your claim form (see Step 3 below).
Step 3: Making a claim
Please read Section 6 for full details of how
to claim. Here are some guidelines and useful
things to remember.
Direct settlement/pay and claim
Direct settlement is where the provider ofyour
treatment claims directly from us, making
things easier for you. The alternative is for youto pay and then claim back the costs from us.
We try to arrange direct settlement wherever
possible, but it has to be with the agreement
of whoever is providing the treatment. In
general, direct settlement can only be arrangedfor in-patient or day-case treatment.
Direct settlement is easier for us to arrange if
you pre-authorise yourtreatment rst, or if
you use a participating hospital or clinic.
What to send
We must receive a fully completed claim form
and the original invoices for yourtreatment,within six months of the treatment date.
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You can download a claim form from our
MembersWorld website, or contact us to send
you one. Remember that ifyourtreatment
is pre-authorised, your pre-authorisationstatement will act as your claim form.
How we make payments
Wherever possible, we will follow the
instructions given to us in the payment section
of the claim form:
z we can pay you or the hospital
z we can pay by cheque or by electronictransfer
we can pay in over 80 currencies
If this is not possible, please write to us with
the details and we will see if an exception can
be made.
Your claim form
You must ensure that your claim form is
fully completed by you and by yourmedical
practitioner. The claim form is important
because it gives us all the information that
we need. Contacting you or yourmedical
practitioner for more information can take
time, and an incomplete claim form is the most
common reason for delayed payments.
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To carry out electronic transfers, we need
to know the full bank name, address, SWIFT
code and (in Europe only) the IBAN number
ofyour bank account. You can give us thisinformation on the claim form.
Tracking a claim
We will process your claim as quickly as
possible. You can easily check the progress of
a claim you have made by logging on to our
MembersWorld* website.
Claim payment statementMyClaim
When your claim has been assessed and paid,
we will send a statement to you to conrm
when and how it was paid, and who received
the payment. Again, please contact us ifyou
have any questions about this information.
About your membership
The Bupa International Selections Egypt plan
is a group insurance plan. You are therefore
one of a group of members, which has a
sponsor (normally the company that you,
the principal member work for).
This plan is governed by an agreement
between yoursponsor and Bupa
International, which covers the terms and
conditions ofyour membership. This meansthat there is no legal contract between you
and Bupa International. Only the sponsor
and Bupa International have legal rights
under the agreement relating to your cover,
and only they can enforce the agreement.
As a member of the plan, you do have access
to our complaints process. This includes the
use of any dispute resolution scheme we havefor our members.
All the following make up our agreement
and must be read together as they set
out the terms and conditions ofyour
membership:
z you, the principal members application
for cover: this includes any quote request,
applications for cover for you and your
dependants (if any) and the declarations
that you, the principal member made
during the application process
z your rules and benets in the
Membership Guide
z your Membership Certicate
The full name ofyour insurer is shown
on your Membership Certicate.
When your cover starts
The start date ofyour membership is
the effective from date shown on your
Membership Certicate.
Ifyoumove to a new country
You, the principal member must inform
your sponsor straight away ifyou change
your specifiedcountry of residence.
Your new country may have different
regulations about health insurance. You,the principal member need to tell your
sponsor of any change so that we can make
sure that you have the right cover and that
all local regulations are being met.
*MembersWorld may not track claims in the USA as
we use a third party here.
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How to claim(summary)
10
Direct settlement Pay and claim
You settle any shortfall with hospital,
clinic or doctor
Bupa International sends your claimpayment statement
Contact the Bupa Egypt helpline on:+20 23762 8685 or from inside Egypt: 16816
egyptcustserv@bupa-intl.com
Bupa International confirms yourcover and benefit limits
Yourmedical practitioner
should complete the medicalinformation section of the claimform. You should complete all othersections, attach invoices and send
the claim to us
Bupa International pays you
Bupa International sendspre-authorisation to you or
to yourhospital
Complete and sign the blank
sections of the statementincluding the patient declaration.
The hospital will attach invoices andsend the claim to us
Bupa International payshospital/clinic
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This section contains your Table of Benets and the accompanying notes.
Before you look at these, please read the important information below about
the kind of costs that we cover.
2.1 Treatment that we cover
For us to cover any treatment that you
receive, it must satisfy all of the following
requirements:
z it is at least consistent with generally
accepted standards of medical practice in
the country in which treatment is being
received
z it is clinically appropriate in terms of type,
duration, location and frequency, and
z it is covered under the terms and
conditions of the plan
We will not pay for treatment which in our
reasonable opinion is inappropriate based on
established clinical and medical practice, and
we are entitled to conduct a review ofyour
treatment, when it is reasonable for us todo so.
2.2 Conditions that we cover
Acute conditions
This plan covers you for treatment of acute
conditions. Acute conditions are diseases,
illnesses or injuries that respond to medical
care without the need for long term or
prolonged treatment. The treatment thatyou receive should be likely to lead to a
complete recovery, or restore you as closely
as possible to your previous state of health.
Please note that this denition above means
that you do not have cover for treatment for
chronic conditions (please see Section 3 for
more information about chronic conditions).
Acute and chronic conditions -
how it works in practice
1. We will cover an acute condition until we
become aware that it is chronic
2. Ifyou develop a condition which is known
to be chronic, we will pay for treatment
to:
z diagnose your condition
z stabilise your condition
but we will not pay for ongoing treatmentor drugs to maintain your health or
control the condition.
3. Ifyou suffer an acute are-up of a chronic
condition we will pay for treatment
you receive during this period. Example:
a chronic condition such as angina is
usually controlled by medication. We
will not pay for drugs, consultations orother treatment to control this condition.
What is covered?
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However, angina could lead to severe
chest pains and the need for a heart
bypass; this is an acute are-up of a
chronic condition. In this situation we
would pay costs associated with the heart
by-pass according to the Table of Benets
(section 2) and the notes (section 2.5).
Please contact the customer services
helpline ifyou have any questions about
acute and chronic conditions.
2.3 Reasonable and customary charges
We will pay for reasonable and customary
costs. This means that the costs charged by
yourtreatment provider should not be more
than they would normally charge and be
representative of charges by other treatment
providers in the same area*.
2.4 Table of Benefits
The Table of Benets shows the benets and
limits that apply to your plan. The notes that
follow it in section 2.5 contain the detailedrules for each benet. You also need to read
Section 3 What is not covered? so that you
understand the exclusions on your plan.
Variations to your benefits
Yoursponsor may have agreed variations to
this benet table with Bupa International.
If so, yoursponsor will inform you of these
variations.
Benefit limits
There are three kinds of benet limits
shown in this table. The per night , the per
operation, and the per procedure limits.
These are the maximum we will pay for
these benets in total for each person each
membership year. This means that once a
benet limit has been reached that benet will
no longer be available until you, the principal
member renew your plan and start a new
membership year.
Currencies
All the benet limits in this Table of Benets
and notes are set out in two currencies:
Sterling and US$. The currency in which
yoursponsor pays us subscriptions is the
currency that applies to your membership for
the purpose of the benet limits.
For example, ifyoursponsor pays us
subscriptions in Sterling then the benet
limits given in Sterling apply to your
membership and US$ limits do not apply
to you.
Ifyou are unsure which level of cover you
have, the currency that applies to your
membership, you can either check on
your Membership Certicate, through
our MembersWorld website or contact thecustomer services helpline.
* Guidelines for fees and medical practice (including established treatment plans, which outline the most appropriate course
of care for a specic condition, operation or procedure) may be published by a government or ofcial medical body. In such
cases, or where published insurance industry standards exist, Bupa International may refer to these when assessing and
paying claims. Charges in excess of published guidelines or reasonable and customary costs may not be paid.
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Note 1: In-patient and day-case treatment
Hospital accommodation and nursing care Note 1aWe pay up to 50 or US$85
each night
Theatre fees, drugs and dressings, prosthetic implants andappliances
Note 1bWe pay up to 300 or US$510each in-patient or day-case stay
Intensive care, intensive therapy, coronary care andhigh dependency unit Note 1c
We pay up to 100 or US$170
each night up to 14 nights eachmembership year
Pathology, X-rays, diagnostic tests therapies andpsychiatric treatment
Note 1dWe pay up to 600 or US$1,020
each membership year
Parent accommodation Note 1eWe pay up to 50 or US$85
each night
Surgeons and anaesthetist fees, includingpre and post-operative care
Note 1fWe pay up to 750 or US$1,275
for each operation
Surgeons and anaesthetist fees for complex majoroperations (in addition to benefit in note 1f)
Note 1gWe pay up to 2,000 or US$3,400
for each operation
Physicians fees Note 1hWe pay up to 250 or US$425
for each procedure
Note 2: Out-patient treatment
Consultants fees for consultations, pathology X-raysdiagnostic tests, therapies and psychiatric treatment
Note 2aWe pay up to 300 or US$510
each membership year
Table of Benefits2.4
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www.bupa-intl.co
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Note 3: Further benefits
Advanced imaging Note 3aWe pay up to 100 or US$170
each membership year
Cancer treatment Note 3bWe pay up to 1,000 or US$1,700
each membership year
Healthline services Note 3c Included
Local road ambulance Note 3dWe pay up to 75 or US$128
each membership year
Note 4: Optional benefits (if purchased)
Primary care; costs for treatment by family doctor andprescribed drugs and dressings
Note 4aWe pay up to 600 or US$1,020
each membership year
Dental treatment Note 4b
We pay 80 percent up to 150or US$255 each membership year
(See notes for details of eligible costs forpreventive, routine, major restorative and
emergency dental treatment)
Optical(Dental treatment and optical must be purchased together
Note 4c
We pay 80 percent up to 100or US$170 each membership year
(See notes for details of eligible costs of eye tests,spectacle lenses, frames and contact lenses)
Maternity cover (after 10 months membership) Note 4dWe pay up to 1,000 or US$1,700
each membership year
Assistance cover (Evacuation and Repatriation) Section 4
See Section 4 for details of the optionalassistance cover. Your Membership
Certificate will show ifyou have purchasedthis cover. The overall annual maximum
benefit limit does not apply.
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Notes to the Table of Benefits
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Each benet described in this section is payable according to the limits
set out in the Table of Benets (Section 2.4).
Note 1: In-patient and day-case treatment
Importantfor all in-patient andday-case treatment costs:
z it must be medically essential for
you to occupy a hospital bed to
receive the treatment
z yourtreatment must be provided,
or overseen, by a consultant
z we pay for accommodation in a
room that is no more expensive than
the hospitals standard single room
with a private bathroom. This means
that we will not pay the extra costs
of a deluxe, executive or VIP suite
etc.
z if the cost oftreatment is linked
to the type of room, we pay the
cost oftreatment at the rate which
would be charged ifyou occupied astandard single room with a private
bathroom
z the hospital where you have your
treatment must be recognised
2.5
Long in-patient stays: 10 daysor longer
In order for us to cover an in-patient
stay lasting 10 days or more, you must
send us a medical report from your
consultant before the eighth night,
conrming:
z your diagnosis
z treatment already given
z treatment planned
z discharge date
1a: Hospital accommodation and nursing
care
We pay charges for yourhospital
accommodation, including all your own mealsand refreshments, and nursing services, you
need as part ofyourtreatment in hospital.
We do not pay for personal items such as
telephone calls, newspapers, guest meals or
cosmetics.
Note: we do not pay for nurses hired in
addition to the hospitals own staff. In the
rare case where a hospital does not providenursing staffwe will pay for the reasonable
cost of hiring a qualified nurse for your
treatment
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We pay for accommodation in a room that
is no more expensive than the hospitals
standard single room with a private bathroom.
This means that we will not pay the extra
costs of a deluxe, executive or VIP suite etc.We pay for the length of stay that is medically
appropriate for the procedure that you are
admitted for.
Examples: unless medically essential, we
do not pay for day-case accommodation
for out-patient treatment (such as
an MRI scan), and we do not pay forin-patient accommodation for day-case
treatment (such as a biopsy).
Please also read Convalescence and
admission for general care in the What is not
covered? section.
1b: Theatre charges, drugs and dressings,
prosthetic implants and appliances
We pay for use of an operating theatre.
We pay for a prosthetic implant needed as
part ofyourtreatment. By this, we mean
an articial body part or appliance which is
designed to form a permanent part ofyour
body and is surgically implanted for one or
more of the following reasons:
z to replace a joint or ligament
z to replace one or more heart valves
z to replace the aorta or an arterial blood
vessel
z to replace a sphincter muscle
z to replace the lens or cornea of the eye
z to act as a heart pacemaker
z to remove excess uid from the brainz to control urinary incontinence (bladder
control)
z to reconstruct a breast following surgery
for cancer when the reconstruction
is carried out as part of the original
treatment for the cancer and you have
obtained our written consent beforereceiving the treatment
z to restore vocal function following
surgery for cancer
We also pay for the following appliances:
z a knee brace which is an essential part
of a surgical operation for the repair to
a cruciate (knee) ligament, or
z a spinal support which is an essential part
of a surgical operation to the spine
1c: Intensive care
We pay for intensive care in an intensive care
unit/intensive therapy unit, high dependency
or coronary care unit (or their equivalents)
when:
z it is an essential part ofyourtreatment
and is required routinely by patients
undergoing the same type oftreatment
as yours, or
z it is medically necessary in the event of
unexpected circumstances, for example
ifyou have an allergic reaction during
surgery
1d: Pathology, x-rays, diagnostic tests,
therapies and psychiatric treatment
We pay for:
z pathology, such as checking blood and
urine samples
z radiology, such as X-rays, and
z diagnostic tests, such aselectrocardiograms (ECGs)
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when recommended by yourconsultant
to help determine or assess your condition,
when carried out in a hospital..
We pay for treatment provided bytherapists (such as physiotherapists) and
complementary medicine practitioners
(such as acupuncturists) if it is needed as part
ofyourtreatment in hospital.
We also pay for psychiatric treatment
you receive in hospital after you have
been a member of the plan (or any Bupa
administered plan which includes cover for
psychiatric treatment) for two years before
the psychiatric treatment.
1e: Parent accommodation
We pay for hospital accommodation for each
night you need to stay with your child in the
same hospital. This is limited to only one
parent each night.
Your child must be:
z aged under 18, and
z a Bupa International member receiving
treatment for which he or she is covered
under their plan
1f: Surgeons and anaesthetist fees,including pre and post-operative care
We pay surgeons and anaesthetists fees for
a surgical operation and all pre- and
postoperative care required during the
in-patient or day-case stay.
Note: this benefit does not include follow-up
consultations with yourconsultant, as these
are paid under benefit Note 2a.
1g: Surgeons and anaesthetist fees for
complex major operations
We pay additional fees for surgeons
and anaesthetists for complex surgical
operations.
1h: Physicians fees
We pay physicians fees for treatment you
receive in hospital if this does not include a
surgical operation, for example ifyou are in
hospital for treatment of a medical condition
such as pneumonia.
Ifyourtreatment includes a surgical
operationwe will only pay physicians fees
if the attendance of a physician is medically
necessary, for example, in the rare event of a
heart attack following a surgical operation.
Note 2: Out-patient treatment
This is treatment which does not normally
require a patient to occupy a hospital bed.
Note 2 details the benets payable for
out-patient treatment only. Ifyou are having
treatment and you are not sure which benet
applies, please call us and we will be happy to
help. Please check the Table of Benets to see
the limits that apply
2a: Consultants fees for consultations,
pathology, X-rays, diagnostic tests,therapies and psychiatric treatment
We pay for consultants fees for consultations,
you receive as an out-patient, this normally
means a meeting with a consultant to assess
your condition.
We pay for:
z pathology, such as checking blood andurine samples, for specic abnormalities
z radiology (such as X-rays), and
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z diagnostic tests such as
electrocardiograms (ECGs)
when recommended by yourconsultant to
help determine or assess your condition.
We pay for costs by therapists and
complementary medicine practitioners for
therapies including acupuncture, osteopathy,
chiropractic and homeopathy.
We pay for consultants fees and
psychologists fees for psychiatric treatment.
We will pay after you have been a member of
the plan (or any Bupa administered plan which
includes cover for psychiatric treatment) for
the whole of the two years leading up to the
psychiatric treatment.
Note 3: Further benefits
Note 3 covers additional benets provided by
your membership of the Selections Egypt plan.
These benets may be in-patient, out-patient or
day-case. Please check the Table of Benets to
see the limits that apply.
3a: Advanced imaging, for example MRI, CT
and PET scans (head and body scanning)
We pay for magnetic resonance imaging (MRI),
computed tomography (CT) and positron
emission tomography (PET) when recommendedby yourconsultant or family doctor.
3b: Cancer treatment
Once cancer is diagnosed, we pay fees that are
related specically to planning and carrying out
treatment for cancer. This includes tests, scans,
consultations and drugs (such as cytotoxic
drugs or chemotherapy).
When the acute phase of cancer treatment
(by which we mean surgery, radiotherapy
or chemotherapy) has been completed, we
will continue to pay this benet for all cancer
treatment specically related to the originaldiagnosis for up to a further ve years.
The ve years will begin on the rst out-patient
consultation following completion of the
acute phase oftreatment. Cover during this
period includes any follow-up tests, scans and
consultations you may require. It also includes
any drugs that may be required to keep the
cancer in remission or to prevent relapse, for
up to ve years.
Ifyourtreatment needs to continue
for more than ve years, please contact
us for pre-authorisation (see Section 5,
Pre-authorisation) before proceeding. It may
be necessary for us to seek a second opinion
as part ofour pre-authorisation process.
3c: Healthline services
This is a telephone advice line which offers
help 24 hours a day, 365 days a year. Please
call +44 (0) 1273 333 911 at any time when
you need to.
The following are some of the services that
may be offered by telephone:
z general medical information from
a health professional
z medical referrals to a physician or
hospital
z medical service referral (ie locating
a physician) and assistance arranging
appointments
z inoculation and visa requirementsinformation
z emergency message transmission
z interpreter and embassy referral
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Note:treatment arranged through this
service may not be covered under your plan.
Please check your cover before proceeding.
3d: Local road ambulanceWe pay for medically necessary travel by
local road ambulance when related to eligible
in-patient or day-case treatment.
Note 4: Optional benefits (if purchased)
4a: Primary care
We pay for costs for treatment by a family
doctor and for the cost of drugs and
dressings prescribed for you by yourmedical
practitioner for eligible treatment. We only
pay for items which need a prescription.
Note: this benet does not include costs
for complementary medicine prescribed or
administered, as these are paid under the
benet described in Note 2a.
4b: Dental treatment
We pay up to 80 percent of eligible costs for
preventive treatment (such as check-ups,
X-rays, scale and polishing), routine
treatment (such as fillings, extractions and
root canal therapy), major restorative or
orthodontic treatment (such as crowns,
bridges or implants), or orthodontic
treatment of overbite or under bite etc.
We pay for emergency dental treatment
that you receive from yourdental
practitioner during your first visit and the
14 days immediately following that first visit
for each dental emergency you have during
the membership year. We do not have to
pay for any dental treatment, related to that
dental emergency, that you receive after the14 days.
By eligible emergency dental treatmentwe
mean emergency dental treatment consisting
of:
z dental examinationz radiography (for example an X-ray)
z replacement of a lost filling
z extraction of a tooth (or tooth root)
z stopping abnormal heavy bleeding
(haemorrhage)
z cutting into an abscess
z dressing a root canal
z prescribed antibiotics
z re-cementing a crown, bridge or inlay
z adjustment or repair to a denture
z construction and fitting of a temporary
crown
z call-out charge
This benefit is available only in conjunction
with the optical benefit.
4c: Optical
We pay up to 80 percent of eligible costs for
one eye test each membership year, which
includes the cost ofyour consultation and
sight/vision testing, eligible costs for spectacle
and contact lenses which are prescribed to
correct a sight/vision problem such as short or
long sight and eligible costs of spectacle frames
only ifyou have been prescribed spectaclelenses.
Your spectacle lens prescription will be required
in support ofyour claim for spectacle frames.
This benet is available only in conjunction with
the dental treatment benet.
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4d: Maternity cover
(after 10 months membership)
We pay maternity benets only after you
have been covered under the Selections
Egypt plan for 10 months.
These benets include for example:
z ante natal care such as ultrasound scans
z hospital charges, obstetricians and
midwives fees for pregnancy and
childbirth (this includes hospital,
obstetricians and other medical fees for
the cost of the delivery ofyour baby by
Caesarean section)
z obstetricians and midwives fees for
delivering your baby at home or birthing
centre
z post natal care required by the mother
immediately following normal childbirth,
such as stitches
z pregnancy and childbirth complications,
by which we mean those conditions
which only ever arise as a direct result of
pregnancy or childbirth
Pregnancy and childbirth complications
include pre-eclampsia, miscarriage,
threatened miscarriage, gestational
diabetes, when the foetus has died and
remains with the placenta in the womb,still birth, heavy bleeding in the hours and
days immediately after childbirth (post
partum haemorrhage), afterbirth left in the
womb after delivery of the baby (retained
placental membranes) and complications
following any of the above conditions.
(Other conditions arising from pregnancy
or childbirth which could also develop
in people who are not pregnant are notcovered by this benet but may be covered
by your other benets).
Note: routine care for your baby
We pay for routine care for the baby, for up to
seven days following birth, from the mothers
maternity benet. Your baby is also covered
for up to seven days routine care followingbirth ifyour baby was born to a surrogate
mother and you, as the intended parent, have
been covered on the Selections Egypt plan for
10 months when the baby is born. Please also
see Section 7.3 Adding dependants. Please
refer to Surrogate parenting, congenital and
hereditary conditions in the What is not
covered section.
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3
There are certain conditions and treatments that we do not cover. Ifyou
are unsure about anything in this section, please contact us for conrmation
before you go for your treatment.
The table below lists the exclusions with any
comments that may apply, and the page
number where you can nd the full rule.
Please note that this table is only a guide, and
that you must read the full rules to make sure
that you understand your cover.
Exclusion Comments See page
1 Addictive conditions and disorders 24
2 Ageing and puberty 24
3 Allergies and allergic disorders 24
4 Articial life maintenance 24
5 Birth control 24
6 Chronic conditions 24
7 Conict and disaster 25
8 Congenital conditions 25
9Convalescence and admission for generalcare
25
10 Cosmetic treatment 25
11 Deafness 25
12 Dental treatment / gum disease 26
13 Developmental problems 26
14 Donor organs 26
15 Experimental treatment 26
16 Eyesight 27
17 Footcare 27
18 Genetic testing 27
19 Health hydros, nature cure clinics etc. 27
20 Hereditary conditions 27
What is not covered?
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Exclusion Comments See page
21 HIV / AIDS 27
22 Infertility treatment 27
23 Obesity 27
24 Persistent vegetative state (PVS)and neurological damage
27
25 Personality disorders 27
26 Physical aids and devices 28
27 Pre-existing conditions 28
28 Preventive and wellness treatment 28
29 Reconstructive or remedial surgery 29
30 Self-inicted injuries 29
31 Sexual problems/gender issues 29
32 Sleep disorders 29
33 Speech disorders 29
34 Surrogate parenting 29
35 Travel costs for treatment 29
36 Unrecognised physician or facility 29
37 Renal failure 30
38 USA treatment 30
39 Vaccinations 30
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24
The following conditions and treatments
are excluded from your plan.
1. Addictive conditions and disorders
Treatment for, or arising from, addictive
conditions and disorders, or from any kind of
substance or alcohol use or misuse.
Example: we do not pay to help you to
stop smoking.
2. Ageing and puberty
Treatment to relieve symptoms caused by
ageing, puberty, or other natural physiological
cause.
3. Allergies and allergic disordersTreatment to de-sensitise or neutralise any
allergic condition or disorder.
4. Artificial life maintenance
Including mechanical ventilation, where such
treatment will not result in your recovery or
restore you to your previous state of health.
5. Birth control
Any type of contraception, sterilisation,
termination of pregnancy or family planning.
6. Chronic conditions
Treatment of chronic conditions. By this, we
mean a disease, illness or injury (including a
mental condition) which has at least one of
the following characteristics:
z has no known cure or recurs
z leads to permanent disabilityz is caused by changes to the body which
cannot be reversed
Important please read
Personal exclusions
- please check your Membership Certicate
to see ifyou have any personal exclusions or
restrictions on your plan. The exclusions inthis section apply in addition to and alongside
any such personal exclusions and restrictions.
General note for all exclusions
For all exclusions in this section, and for any
personal exclusions or restrictions shown on
your Membership Certicate, please note that:
1. we do not pay for conditions which are
directly related to excluded conditions
or treatments
2. we do not pay for any additional or
increased costs arising from excluded
conditions or treatments
3. we do not pay for complications arising
from excluded conditions or treatments
Example:
You have a personal exclusion for
diabetes.
1. Ifyour diabetes were to cause
glaucoma, we would not pay fortreatment for the glaucoma.
2. If while receiving treatment for another
condition, you need to stay extra days
in hospital because ofyour diabetes,
we would not pay for these extra days.
3. If complications arise from excluded
treatment such as cosmetic or
refractive eye procedures, we will
not pay to treat these complications.
Exceptions
This section describes some circumstances
where exceptions can be made to exclusions
or restrictions. Where this is the case, benet
is payable up to the limits set out in your
Table of Benets in Section 2.
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z requires the person with the condition to
be specially trained or rehabilitated
z needs prolonged supervision, monitoring
or treatment
7. Conflict and disaster
Treatment for any disease, illness or
injury resulting from nuclear or chemical
contamination, war, riot, revolution, acts
of terrorism or any similar event, if one
or more of the following apply:
z you have put yourself in danger by
entering a known area of conict where
active ghting or insurrections are taking
place
z you were an active participant
z you have displayed a blatant disregard
for personal safety
8. Congenital conditions
Treatment received after the rst 14 days
following birth for any abnormality, deformity,
disease, illness or injury present at birth,
whether diagnosed or not, except cancer.
9. Convalescence and admission for
general care
Hospital accommodation when it is used solely
or primarily for any of the following purposes:
z convalescence, supervision, pain
management or any other purpose other
than for receiving eligible treatment, of a
type which normally requires you to stay
in hospital
z receiving general nursing care or any other
services which do not require you to be
in hospital, and could be provided in a
nursing home or other establishment thatis not a hospital
z receiving services from a therapist or
complementary medicine practitioner
z receiving services which would not
normally require trained medical
professionals such as help in walking,bathing or preparing meals
10. Cosmetic treatment
Treatment undergone for cosmetic or
psychological reasons to improve your
appearance, such as a re-modelled nose,
facelift or cosmetic dentistry. This includes:
z dental implants to replace a sound
natural tooth
z hair transplants for any reason
z treatment related to or arising from the
removal of non-diseased, or surplus or
fat tissue, whether or not it is needed for
medical or psychological reasons
z any treatment for a procedure to change
the shape or appearance ofyour breast(s)
whether or not it is needed for medical
or psychological reasons: unless for
reconstruction carried out as part of the
original treatment for the cancer, when
you have obtained our written consent
before receiving the treatment
(see Reconstructive or remedial surgery
in this section)
Examples: we do not pay for breast
reduction for backache or gynaecomastia
(the enlargement of breasts in men).
11. Deafness
Treatment for or arising from deafness or
partial hearing loss caused by a congenital
abnormality, maturing or ageing.
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12. Dental treatment/gum disease
This includes surgical operations for the
treatment of bone disease when related
to gum disease or damage, or treatment
for, or arising from disorders of thetemporomandibular joint.
This also includes emergency dental
treatment.
Examples: we do not pay for tooth decay,
gum disease, jaw shrinkage or loss,
damaged teeth, etc.
Please see Note 4b in the What is
covered? section for details ofyour
dental benefit
Exception: We pay for a surgical operation
carried out by a consultant to:
z put a natural tooth back into a jaw bone
after it is knocked out or dislodged in an
accident
z treat irreversible bone disease involving
the jaw(s) which cannot be treated in any
other way, but not if it is related to gum
disease or tooth disease or damage
z surgically remove a complicated, buried
or impacted tooth root, for example inthe case of an impacted wisdom tooth
13. Developmental problems
Treatment for, or related to developmental
problems, including:
z learning difculties, such as dyslexia
z behavioural problems, including
attention decit hyperactivity disorder(ADHD), or
z problems related to physical
development, including (but not
restricted to) short height
14. Donor organsTreatment costs for, or as a result of the
following:
z transplants involving mechanical or
animal organs
z the removal of a donor organ from a
donor
z the removal of an organ from you for
purposes of transplantation into another
person
z the harvesting and storage of stem cells,
when this is carried out as a preventive
measure against future possible diseases
or illness
z the purchase of a donor organ
15. Experimental treatment
Treatment or prescribed medicines which in
our reasonable opinion, based on advice of
the local public authority in the country where
yourtreatment takes place, are experimental
or have not proved to be effective.
Treatment or clinical trials which have not yet
been approved in the country in which you
are receiving treatment.
Prescribed medicines used for purposes other
than those dened under their licence, which
may vary from country to country.
Note: ifyou are unsure whether your
treatment may be experimental, please
contact us.We reserve the right to ask for full
clinical details from yourconsultant beforeapproving any treatment, in which case you
must receive our written agreement before
the treatment takes place.
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16. Eyesight
Treatment to correct eyesight, unless
required as the result of an injury or acute
condition.
Examples: we will not pay for routine
eye examinations, contact lenses,
spectacles or refractive eye procedures.
We will pay for treatment of a detached
retina, glaucoma or cataracts.
Please see Note 4c in the What is covered?
section for details ofyouroptical benefit.
17. Footcare
Treatment for corns, calluses, or thickened
or misshapen nails.
18. Genetic testing
Genetic tests, when such tests are solely
performed to determine whether or not you
may be genetically likely to develop a medical
condition.
Example: we do not pay for tests used
to determine whether you may develop
Alzheimers disease, when that disease
is not present.
19. Health hydros, nature cure
clinics etc.
Treatment or services received in
health hydros, nature cure clinics or any
establishment that is not a hospital.
20. Hereditary conditions
Treatment of abnormalities, deformities,diseases or illnesses that are only present
because they have been passed down through
the generations ofyour family, except cancer.
21. HIV and AIDS
Treatment for, or arising from, HIV or AIDS,
including any condition that is related to HIV
or AIDS, ifyour current period of membership
is less than ve years.
22. Infertility treatment
Treatment to assist reproduction, including
but not limited to IVF treatment.
Note:we pay for reasonable investigations
into the causes of infertility if:
z neither you nor your partner had been
aware of any problems before joining, and
z you have both been members of this
plan (or any Bupa administered plan
which included cover for this type of
investigation) for a continuous period of
two years before the investigations start
Once the cause is conrmed, we will not pay
for any additional investigations in the future.
23. Obesity
Treatment for, or required as a result of
obesity.
24. Persistent vegetative state (PVS) and
neurological damage
We will not pay for in-patient treatment formore than 90 continuous days for permanent
neurological damage or ifyou are in a
persistent vegetative state.
25. Personality disorders
Treatment of personality disorders, including
but not limited to:
z affective personality disorderz schizoid personality (not schizophrenia)
z histrionic personality disorder
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26. Physical aids and devices
Any physical aid or device which is not a
prosthetic implant, prosthetic device, or
dened as an appliance.
Examples: we will not pay for hearing
aids, spectacles, contact lenses, crutches
or walking sticks.
27. Pre-existing conditions
Any treatment for a pre-existing condition,
related symptoms, or any condition that
results from or is related to a pre-existing
condition, unless:
z we were given all the medical information
that we asked for during your application
for your current continuous period of
membership
z we did not specically exclude cover
for the pre-existing condition on your
Membership Certicate, and
z you did not know about the pre-existing
condition before the effective from
date on the rst Membership Certicate
for your current continuous period of
membership
Note: please contact us before yourrenewal
date ifyou would like us to review a personalexclusion. We may remove your exclusion if,
in our opinion, no further treatment will be
either directly or indirectly required for the
condition, or for any related condition. There
are some personal exclusions that, due to their
nature, we will not review.
To carry out a review, we must receive full
current clinical details from yourfamily
doctor or consultant. Any costs incurred in
obtaining these details are not covered under
your plan and are your responsibility.
Please note: this exclusion does not
apply ifyoursponsor has purchased
cover with medical history disregarded.
Ifyou are unsure whether you have
this cover, please contact the customer
services helpline.
For pre-existing conditions for newborns,
please see the exclusions for congenital and
hereditary conditions in this section.
28. Preventive and wellness treatment
Health screening, including routine health
checks, or any preventive treatment.
Note:we may pay for prophylactic surgery
when:
z there is a signicant family history of the
disease for example ovarian cancer, which
is part of a genetic cancer syndrome, and/
or
z you have positive results from genetic
testing (please note that we will not payfor the genetic testing)
Please contact us for pre-authorisation (see
Section 5) before proceeding with treatment.
It may be necessary for us to seek a second
opinion as part ofour pre-authorisation
process.
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29. Reconstructive or remedial surgery
Treatment required to restore your
appearance after an illness, injury or
previous surgery, unless:
z the treatment is a surgical operation
to restore your appearance after an
accident, or as the result of surgery
for cancer, if either of these takes
place during your current continuous
membership of the plan
z the treatment is carried out as part of
the original treatment for the accident
or cancer
z you have obtained our written consent
before the treatment takes place
30. Self-inflicted injuries
Treatment for, or arising from, an injury that
you have intentionally inicted on yourself,
for example during a suicide attempt.
31. Sexual problems and gender issues
Treatment of any sexual problem including
impotence (whatever the cause) and sex
changes or gender reassignments.
32. Sleep disorders
Treatment for insomnia, sleep apnoea,
snoring, or any other sleep-related breathing
problem.
33. Speech disorders
Treatment for speech disorders, including
stammering, unless the following all apply:
z the treatment is short term therapy
which is medically necessary as part of
active treatment for an acute condition
such as a strokez the speech therapy takes place during
and/or immediately following the
treatment for the acute condition
z the speech therapy is recommended
by the consultant in charge ofyour
treatment, and is provided by a therapist
in which case we may pay at our discretion.
34. Surrogate parenting
Treatment directly related to surrogacy.
This applies:
z to you ifyou act as a surrogate, and
z to anyone else acting as a surrogate for you
35. Travel costs for treatmentAny travel costs related to receiving
treatment, unless otherwise covered by:
z local road ambulance benet (see note 3d)
Example:
z we do not pay for taxis or other travel
expenses for you to visit a medical
practitioner
z we do not pay for travel time or the
cost of any transport expenses charged
by a medical practitioner to visit you
36. Unrecognised physician or facility
z
Treatment provided by a medicalpractitioner who is not recognised by the
relevant authorities in the country where
the treatment takes place as having
specialised knowledge, or expertise in,
the treatment of the disease, illness or
injury being treated.
z Treatment in any hospital, or by any
medical practitioner or any other
provider of services, to whom we havesent a written notice that we no longer
recognise them for the purposes ofour
plans.
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*Please note: due to the cost oftreatment in the USA, members must pre-authorise all treatment. This is to make sure that the
treatment you wish to have is eligible and so that we can advise you, in advance, ifyou will need to contribute to your own
treatment costs.30
z Treatment provided by anyone with
the same residence as you or who is a
member ofyour immediate family.
37. Renal failureSupportive treatment for renal failure,
including dialysis.
This exclusion will not apply if:
Treatment directly related to surrogacy.
This applies:
z the patient had been in hospital for the
immediate purpose of receiving a kidney
transplant, or
z the costs were incurred in connection with
acute secondary failure when the dialysis
was part of intensive care
38. USA treatment
If USA cover has not been purchased, then any
treatment received in the USA is ineligible*:
z after the 28th day ofyour visit to the USA
z for any condition of which you were
aware before your visit to the USA
z when arrangements were not authorised
by our agents in the USA, and
z when Bupa International knows or
suspects that you travelled to the USA forthe purpose of receiving treatment for
a condition, when the symptoms of the
condition were apparent to you before
travelling. This applies whether or not
yourtreatment was the main or sole
purpose ofyour visit
Note: you can claim for unforeseen
treatment received within 28 days ofyour
arrival in the USA, you must send evidence of
your arrival date with your claim. Examples
include a certied photocopy ofyour airlineticket or your visa stamp.
Bupa InternationalsService Partner in the
USoperates a national network ofhospitals,
clinics and medical practitioners. This is the
USprovider network. You must contact
our US Service Partner before you have
treatment, and they can help to nd a
suitable network provider for you.
For eligible treatment that takes place in the
USusing theUSprovider network, benet is
paid at 100 percent. When eligible treatment
takes place in theUSbut outside the provider
network, benet is paid at 80 percent.
If USA cover has been purchased, then
treatment received in the USA is ineligible
when:
z arrangements for the treatment were not
authorised by our agents in the USA, and
z Bupa International knows or suspects
that you purchased cover for and travelled
to the USA for the purpose of receiving
treatment for a condition, when thesymptoms of the condition were apparent
to you before buying the cover. This
applies whether or not yourtreatment
was the main or sole purpose ofyour visit
39. Vaccinations
Vaccinations, as these are not active
treatment of acute illness, they are not eligible
for benet.
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4
Assistance cover(optional if purchased)
This section contains the rules and information for Assistance Cover, an
optional benet which helps you ifyou need to travel to get the treatment
that you need.
Note: there are two levels of Assistance Cover: Evacuation and Repatriation. Your Membership
Certicate will show ifyou have Evacuation or Repatriation but you can visit the MembersWorld
website or contact the customer services helpline ifyou are unsure.
What is Assistance Cover?
The Evacuation and Repatriation options both
cover you for reasonable transport costs
to the nearest medical facility where the
treatment that you need is available, if it is
not available locally. Repatriation also gives
you the option of returning to yourspecified
country of nationality or yourspecified
country of residence.
We may not be able to arrange Evacuation or
Repatriation in cases where the local situation
makes it impossible, unreasonably dangerousor impractical to enter the area; for example
from an oil rig or within a war zone.
4.1 Assistance Covergeneral rules
The following rules apply to both the
Evacuation and Repatriation levels of cover:
z you must contact our appointed
representatives for conrmation beforeyou travel, on +44 (0) 1273 333 911
z our appointed representatives must
agree the arrangements with you
z Assistance Cover is applicable for
in-patient and day-case treatment only
z the treatment must be recommended by
yourconsultant or family doctor and,
for medical reasons, not available locally
z the treatment must be eligible under
your plan.
z you must have cover for the country you
are being treated in, for example the USA
z you must have the appropriate level of
Assistance Cover in place before you
need the treatment
Evacuation or Repatriation will not be eligible
ifyou were aware of the symptoms ofyour
condition before applying for Assistance Cover.
We will not approve a transfer which in our
reasonable opinion is inappropriate based
on established clinical and medical practice,
and we are entitled to conduct a review of
your case, when it is reasonable for us todo so. Evacuation or Repatriation will not be
authorised if this would be against medical
advice.
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4.2 How to arrange your Evacuation or
Repatriation
Arrangements for Evacuation will be made by
our appointed representatives and must beconrmed in advance by calling
+ 44 (0) 1273 333 911. You must provide
us with any information or proof that we may
reasonably ask you for to support your request.
We will only pay if all arrangements are agreed
in advance by Bupa Internationals appointed
representatives.
4.3 Evacuation cover:what we will pay for
Ifyou have Evacuation cover it will be shown
on your Membership Certicate. Ifyou are still
unsure you can visit our MembersWorld website
or contact the customer services helpline.
z We will pay in full for your reasonable
transport costs for day-case or in-patient
treatment. It may also be authorised ifyou
need advanced imaging or cancer treatment
such as radiotherapy or chemotherapy.
z We will only pay for Evacuation to the nearest
place where the required treatment is
available. This could be to another part of the
country that you are in, and may not be your
home country.
z
We will pay for the reasonable travel costsfor another Bupa International member to
accompany you, but only if it is medically
necessary.
z We will also pay for the reasonable costs
ofyour, and the accompanying members,
return journey to the place you were
evacuated from. All arrangements for your
return should be approved in advance
by Bupa International or our appointedrepresentatives and the journey must be
made within fourteen days of the end of the
treatment. We will pay for either:
z the reasonable cost of the return journey
by the most direct route available by land
or sea, or
z the cost of an economy class air ticket bythe most direct route available, whichever
is the lesser amount.
z we will pay reasonable costs for the
transportation only ofyour body, subject
to airline requirements and restrictions,
to your home country, in the event of
your death while you are away from
home. We do not pay for burial or
cremation, the cost of burial caskets etc,
or the transport costs for someone to
collect or accompany your remains
Note: we do not pay for any other costs related
to the evacuation such as hotel accommodation
or taxis. Costs of any treatment you receive
are not payable under Evacuation cover, but are
payable from your medical cover as described
in your Table of Benets and the What is
covered? section of this guide.
Please also note that for medical reasons the
member receiving treatment may travel in a
different class from their companion.
4.4 Repatriation cover:
what we will pay forIfyou have Repatriation cover it will be shown
on your Membership Certicate. Ifyou are
still unsure you can visit our MembersWorld
website or contact the customer services
helpline. Repatriation cover also includes
Evacuation cover see 4.3 above.
z We will pay in full for your reasonable
transport costs for day-case or in-patienttreatment.
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z We will pay for repatriation to your
specified country of nationality or your
specified country of residence.
z We will pay for one repatriation for eachillness or injury per lifetime.
z We will pay the reasonable costs for a
relative or your partner to accompany
you to yourspecified country of
nationality or your specified country of
residence ifwe have authorised this in
advance of the repatriation.
z We will also pay an allowance of up to
Sterling25, US$50 or Euro37 per day
for up to 10 days to cover the living
expenses of the person accompanying
you.
z We will pay for you and the person
accompanying you to return to
where you were repatriated from.
All arrangements for your return
must be approved in advance by
Bupa International or our appointed
representatives and you must make
the return journey within fourteen days
of the end of the treatment you were
repatriated for. We will pay either:
z the reasonable cost of the return
journey by the most direct route
available by land or sea, orz the cost of a scheduled return
economy class air ticket by the most
direct route available, whichever is the
lesser amount
z we will pay reasonable costs for the
transportation only ofyour body,
subject to airline requirements and
restrictions, to your home country, inthe event ofyour death while you are
away from home. We do not pay for
burial or cremation, the cost of burial
caskets etc, or the transport costs for
someone to collect or accompany your
remains
Note:we do not pay for any other costs
related to the repatriation such as hotel
accommodation or taxis. Costs of any
treatment you receive are not payable under
Repatriation cover, but are payable from your
medical cover as described in your Table of
Benets and the What is covered? section of
this guide.
Please also note that for medical reasons the
member receiving treatment may travel in a
different class from their companion.
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5
This section contains rules and information about what pre-authorisation
means and how it works.
5.1 What pre-authorisation meansIfwe pre-authorise yourtreatment, this
means that we will pay up to the limits of
your plan provided that all of the following
requirements are met:
z the treatment is eligible treatment that
is covered by your plan
z you have an active membership at the
time that treatment takes place
z your subscriptions are paid up to date
z the treatment carried out matches the
treatment authorised
z you have provided a full disclosure of the
condition and treatment required
z you have enough benet entitlement to
cover the cost of the treatment
z
your condition is not a pre-existingcondition (see Section 3, What is not
covered?)
z the treatment is medically necessary
z the treatment takes place within 31 days
after pre-authorisation is given
5.2 Treatment we can pre-authorise
We can pre-authorise in-patient and
day-case treatment, cancer treatment andMRI, CT or PET scans.
5.3 Length of stay(in-patient treatment)
Your pre-authorisation will specify an
approved length of stay for in-patient
treatment. This is the number of days in
hospital that we will cover you for. Ifyour
treatment will take longer than this approved
length of stay, then you or yourconsultant
must contact us for an extension to the
pre-authorisation.
5.4 Treatment in the USA
All in-patient and day-case treatment,
cancer treatment and MRI, CT or PET scans
in the USA must be pre-authorised. Ifyou are
going to receive any of these treatments,
ask your medical provider to contact
Bupa International for pre-authorisation.All the information they need is on your
Membership Card.
We have made special arrangements ifyou
need to be hospitalised in the USA. These
include access to a select network of quality
medical providers and direct settlement
of all covered expenses when you receive
treatment in a networkhospital.
Pre-authorisation
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Treatment which has not been
pre-authorised
Ifyou choose not to get yourtreatment
pre-authorised, we will only pay 50 percenttowards the cost of covered treatment.
Of course we understand that there are
times when you cannot get yourtreatment
pre-authorised, such as in an emergency. If
you are taken to hospital in an emergency, it
is important that you arrange for the hospital
to contact us within 48 hours ofyour
admission. We can then make sure you are
getting the right care, and in the right place.
Ifyou have been taken to a hospital which is
not part of the network and, if it is the best
thing for you,we will arrange for you to be
moved to a networkhospital to continue
yourtreatment once you are stable.
Ifwe have been notied within 48 hours of an
emergency admission to hospital, we will not
ask you to share the cost ofyourtreatment.
Out of network treatment
Ifyourtreatment has been pre-authorised,
but you choose not to go to a network
hospital, we will only pay 80 percent towards
the cost of covered treatment.
There may be times when it is not possible
for you to be treated at a networkhospital.
These include:
z where there is no networkhospital
within 30 miles ofyour address, and
z when the treatment you need is not
available in the networkhospital
In these cases, we will not ask you to share
the cost ofyourtreatment.
5.5 Important rules
Please note that pre-authorisation is only valid
if all the details of the authorised treatment,
including dates and locations, match those ofthe treatment received. If there is a change
in the treatment required, ifyou need to
have further treatment, or if any other details
change, then you or yourconsultant must
contact us to pre-authorise this separately. We
make our decision to approve yourtreatment
based on the information given to us. We
reserve the right to withdraw our decision if
additional information is withheld or not given
to us at the time the decision is being made.
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6.1 How to make a claimClaim forms
Your claim form is important as it gives us the
information that we need to process your
claim. If it is not fully completed we may have
to ask for more information. This can delay
payment ofyour claim.
You must complete a new claim form:
z for each member
z for each condition
z for each in-patient or day-case stay, and
z for each currency of claim
If a condition continues over six months,
we will ask for a further claim form to be
completed.
What to send us
You need to return the completed form to
us by post, with the original invoices, as soon
as possible. This must be within six months of
receiving the treatment for which you are
claiming. Invoices sent to us after six months
will not normally be paid.
6
At times of ill health, you want to concentrate on getting well. We will do
everything we can to make your claim as simple and straightforward as
possible.
Requests for further information
We may need to ask you for further
information to support your claim. Ifwe do,
you must provide this. Examples of things we
might ask for include:
z medical reports and other information
about the treatment for which you are
claiming
z the results of any medical examination
performed at our expense by an
independent medical practitioner
appointed by us
z written conrmation from you as to
whether you think you can recover the
costs you are claiming from another
person or insurance company
Ifyou do not provide the information that we
ask for, we may not pay your claim in full.
Please also see Correspondence in
Section 7.6.
Making a claim
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Important
When making a claim please note:
z you must have received the treatmentwhile covered under your membership
z payment ofyour claim will be under the
terms ofyour membership and up to the
benet levels shown, that apply to you at
the time you receive the treatment
z we will only pay for treatment costs
actually incurred by you, not deposits
or advance invoices or registration/
administration fees charged by the
provider oftreatment
z we will only pay for treatment costs that
are reasonable and customary
z we do not return original documents such
as invoices or letters. However, we will be
pleased to return certied copies ifyou
ask us when you submit your claim
Confirmation of your claim
We will always send conrmation of how we
have dealt with a claim. For child dependants
(those aged under 18 years), we will write
to the principal member. If the claim is
for treatment received by the principal
member, or an adult dependant (those aged
over 18 years), we will write directly to the
individual concerned.
6.2 How your claim will be paid
Wherever possible, we will follow the
instructions given to us in the Payment
details section of the claim form.
Who we will pay
We will only make payments to the member
who received the treatment, the provider ofthe treatment, the principal member of the
membership or the executor or administrator
of the members estate. We will not make
payments to anyone else.
Payment method and bank charges
We will make payment where possible by
electronic transfer or by cheque. Payments
made by electronic transfer are quick, secure
and convenient. To receive payment by
electronic transfer, we need the full bank
account, SWIFT code, bank address details and
(in Europe only) IBAN number to be provided
on the claim form.
We will instruct our bank to recharge the
administration fee relating to the cost of
making the electronic transfer to us but we
cannot guarantee that these charges will
always be passed back for us to pay. In the
event that your local bank makes a charge for
a wire transfer we will aim to refund this as
well. Any other bank charges or fees, such as
for currency exchange, are your responsibility,
unless they are charged as a result ofour
error.
Cheques are no longer valid if they are not
cashed within 12 months. Ifyou have an
out-of-date cheque, please contact customer
services, who will be happy to arrange areplacement.
Payment currency and conversions
We can pay in the currency in which your
sponsor pays your subscriptions, the currency
of the invoices you send us, or the currency of
your bank account.
We cannot pay you in any other currency.
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Sometimes, the international banking
regulations do not allow us to make a
payment in the currency you have asked for.
If so, we will send a payment in the currencyofyoursponsors subscriptions.
Ifwe have to make a conversion from one
currency to another we will use the exchange
rate that applies on either the date on which
the invoices were issued or the last date of the
treatment, whichever is later.
The exchange rate used will be the average
of the buying and selling rates across a wide
range of quoted rates by the banks in London
on the date in question. If the date is not a
working day we will use the exchange rate
that applies on the last working day before
that date.
6.3 Other claim information
Discretionary payments
We may, in certain situations, make
discretionary or ex gratia payments towards
yourtreatment. Ifwe make any payment
on this basis, this will still count towards the
overall maximum amount we will pay under
your membership. Making these payments
does not oblige us to pay them in the future.
We do not have to pay for treatment that
is not covered by your plan, even ifwe have
paid an earlier claim for a similar or identical
treatment.
Overpayment of claims
Ifwe overpay you for your claim, we reserve
the right to deduct the overpaid amount from
future claims or seek repayment from you.
Claiming for treatment when others are
responsible
You must complete the appropriate section
of the claim form ifyou are claiming fortreatment that is needed when someone else
is at fault, for example in a road accident in
which you are a victim. If so, you will need to
take any reasonable steps we ask ofyou to:
z recover from the person at fault (such as
through their insurance company) the
cost of the treatment paid for by Bupa
International, and
z claim interest ifyou are entitled to do so
Note: Subrogation
In the event of any payment of any claim
under your membership, we or any person
or company that it nominates may be
subrogated to all rights of recovery of the
member and any person entitled to the
benets of this coverage. The member shall
sign and deliver all documents and papers
and do whatever else is necessary to secure
such subrogated rights to us or its nominated
party. The member shall do nothing after the
claim to prejudice such rights.
Claiming with joint or double insurance
You must complete the appropriate sectionon the claim form, ifyou have any other
insurance cover for the cost of the treatment
or benets you have claimed from us. Ifyou
do have other insurance cover, this must
be disclosed to us when claiming, and we
will only pay our share of the cost of the
treatment or benets claimed.
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7
This section contains the rules about your membership, including when it
will start and end, renewing your plan, how you, the principal membercan
change your cover and general information.
7.1 Paying subscriptions and othercharges
Your sponsor has to pay any and all
subscriptions due to Bupa International
under the agreement, together with any
other charges (such as insurance premium tax)
that may be payable.
7.2 Starting and renewing your
membership
When your cover starts
Your membership starts on the effective
date shown on the rst Membership
Certicate that we sent you, the principal
member for your current continuous period
ofBupa International Selections Egypt plan
membership.
When cover starts for others on your
membership
If any other person is included as a
dependant under your, the principal
members membership, their membership
will start on the effective date on the
rst Membership Certicate we sent you
for your current continuous period of
Bupa International Selections Egypt planmembership which lists them as a dependant.
Their membership can continue for as long
as you, the principal member remain a
member of the plan.
Ifyour, the principal members membership
ceases, your dependants can then, of course,
apply for membership in their own right.
Renewing your membership
The renewal ofyour membership is subject
to your sponsor renewing your membership
under the agreement.
7.3 Adding dependants
Ifyour sponsor agrees, you, the principal
member may apply to include any ofyour
family members under your membership as
one ofyour dependants. To apply you, theprincipal member will need to complete an
Additional Members form.
7.4 Ending your membership
1. Your sponsor can end your, the principal
members membership, or that of any
ofyour dependants, from the rst
day of a month by writing to us.We
cannot backdate the cancellation ofyourmembership.
Your membership
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2. Your membership will automatically end:
z if the agreement between Bupa
International and your sponsor isterminated
z ifyour sponsor does not renew your
membership
z ifyour sponsor does not pay
subscriptions or any other payment due
under the agreement for you or for any
other person
z if the membership of the principal
member ends
z upon the death of the principal member
Specified country of residence
You, the principal member must tell your
sponsor ifyourspecified country of
residence or your country of citizenship
changes. We may need to end your
membership if the change results in a breach
of regulations governing the provision of
healthcare cover to local nationals, residents
or citizens.
The details of regulations vary from country to
country and may change at any time.
In some countries we have local partners
who are licensed to provide insurancecover but which are administered by
Bupa International. This means that
customers experience the same quality
Bupa International service.
Ifyou change your citizenship to a country
where we have a local partner, in most cases
you will be able to transfer to our partners
insurance policy without further medicalunderwriting. You may also be entitled to
retain your continuity ofBupa International
membership; which means that for those
benets which arent covered until you have
been a member for a certain period, the
time you were a member with us will count
towards that. Please note that ifyou requesta transfer to a local partner, we will have to
share your personal information and medical
history with the local partner.
Ifyou change your residency or citizenship,
please call the customer services helpline
so we can conrm ifyourmembership is
affected, and, if so, whether we can offer you
a transfer service.
Important please read
Bupa International can end a persons
membership and that of all the other
people listed on the Membership
Certicate if there is reasonable evidence
that any person concerned has misled,
or attempted to mislead us. By this,
we mean giving false information or
keeping necessary information from us,
or working with another party to give us
false information, either intentionally or
carelessly, which may inuence us when
deciding:
z
whether you (or they) can join theplan
z what subscriptions you have to pay
z whether we have to pay any claim
After your Selections Egypt membership
ends
You, the principal member can apply to
transfer to a personal Bupa Internationalplan ifyour membership ofyour group
plan ends. You can also apply for your
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dependants to transfer with you. Please
contact the customer service helpline for
more information.
7.5 Making changes to your cover
The terms and conditions ofyour
membership may be changed from time to
time by agreement between your sponsor
and Bupa International.
Amending your Membership Certificate
We will send you, the principal member a
new Membership Certicate if:
z with the sponsors approval, you, the
principal member add a new dependant
to your membership
z we
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