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This individual health plan from Sagicor is designed to provide primary medical insurance coverage for Jamaican residents who don't have coverage through their employer or other groups. It protects individuals and their families from financial hardships resulting from sickness or injury. The plan is a yearly, renewable plan available to any individual up to the age of 65 years and ceases at age 70.

Benefits under this policy will not duplicate the benefits that the insured has under any other health insurance plan but will be coordinated with all other health insurance plans so that the total amount payable does not exceed 100% of the incurred charges. Further, the amount of benefits payable under this policy will not exceed the maximum amount established for this benefit. For example, if you undergo surgery costing $100,000 and your other plans pay $80,000, then this policy will pay the remaining $20,000.

A waiting period of six (6) months applies to all pre-existing conditions.

SCHEDULE OF BENEFITS
  • HOSPITAL & SURGERY BENEFITS

    The following benefits are applicable to the insured:

    Covered Services: Plan Pays
    a) Semi-private room and board 80% of R&C
    b) Other covered in-hospital services and supplies including drugs, injections, dressings, laboratory tests, x-rays, operating theatre fees, recovery room and nursing services 80% of Cost
    c) Surgeon's fees/surgical maximum 80% of R&C
    d) Surgical assistance (subject to approval) 30% of Surgeon's Limit
    e) Anaesthesia conversion percentage 40% of Surgeon's Fees Limit
    d) Surgical assistance (subject to approval) 30% of Surgeon's Limit
    f) Hospitalization for treatment of mental or nervous including those resulting from alcohol or drug abuse up to a maximum of 10 days per year As in (a) and (b) above
    g) Hospital doctor's visits (other than by surgeon) 80% of R&C
  • THERAPEUTIC SERVICES

    The following benefits are applicable to the insured:

    Covered Services: Plan Pays
    a) Chemotherapy 80% of R&C
    b) Renal Dialysis 80% of R&C
    c) Radiation Therapy 80% of R&C

    The maximum annual Benefit for benefits covered under items Hospital & Surgery and Therapeutic Services above is $1,000,000 per benefit period.

  • SPECIALISED DIAGNOSTIC PROCEDURES

    All specialised diagnostic procedures must be pre-certified prior to the commencement of the procedure. No benefits are payable under this clause for specialised diagnostic procedures given during confinement by the insured in a hospital.

    Covered Services: Plan Pays
    a) Computerised Tomography (CT Scan) 80% of R&C
    b) Magnetic Resonance Imaging (MRI) 80% of R&C
    c) Electrocardiograph (ECG) 80% of R&C
    d) Cardiac Stress Test 80% of R&C

    The maximum annual benefit for benefits covered under this item is $300,000 per policy year.

  • The maximum lifetime benefit payable for Hospital & Surgery, Therapeutic Services and Specialised Diagnostic Procedures is $5,000,000.00
  • OVERSEAS EMERGENCY MEDICAL SERVICES

    For overseas emergency medical services, please contact the Canadian Medical Network (CMN) within 24 hours of the onset or occurrence of the medical emergency using any of the following emergency numbers:

    • 1-866-274-1755(Toll Free)
    • 1-905-669-4308 (Collect)
    • 1-905-669-4308 (Fax)

    Calls to the Assistance Centre can be made by the insured or someone on his/her behalf for:

    • Medical services
    • Hospital services
    • Physician services rendered in a hospital
    • Ambulance services
    • Miscellaneous services and supplies provided by a hospital
    • Emergency dental services
    Benefits payable after a deductible of US $1,000
    If Participating Providers render the Medical Services 100%
    If Non-participating Providers render the Medical Services 50%

    For Emergency Dental Services

    Per Benefit Period US $1,000
  • FLEXIBLE BENEFITS

    The flexible benefit is a spending account which allows the insured to pre-pay the cost of everyday medical expenses. It requires a regular additional premium in multiples of $1,000 monthly. Amounts added to the spending account accumulate and are used to pay benefits for prescription drugs; visits to any medical doctor; dental needs; optical needs; outpatient X-rays and laboratory tests.

    Credit is advanced to pay the first claim in any policy year up to a maximum of $3,000 in the event that the cost of the benefit is greater than the balance in the fund. Any unused balance in the spending account at the end of a policy year is carried over at renewal. No interest is applied to the credited amount.

    The amount paid for the flexible benefits may be changed at any policy anniversary.

    Coverage includes but is not limited to:

    • Outpatient Benefits, such as:
      • Office visits
      • Specialist consultations
      • Diagnostic X-ray & laboratory benefits
      • Prescribed drugs & medications
      • Dental & Optical services
    Premium Payment

    Premiums are payable yearly, half-yearly, quarterly or monthly. Premiums are accepted via Preauthorised Payment Plan (PAP) or Salary Deduction (SD). Where a flexible benefit premium is paid, it forms part of the contractual premium and is payable at the same time as the base premium. The premium rate at each policy anniversary is that applicable to the policyholder’s attained age and this rate can be changed at the company’s discretion subject to written notice of at least forty-five (45) days.

    Claim Processing

    All claims under the policy must be submitted within ninety (90) days of the event giving rise to the claim. They must be accurate, complete and accompanied by original proof of loss attached.

    Termination

    The plan terminates:

    • When any planned premium remains outstanding for a period of thirty (30) days
    • At the insured’s 70th birthday
    • Upon the determination of non-disclosed or misrepresented material facts on the application of the insured
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