Access Rights 

This refers to the right an Enrolee will have to a category of Providers/Hospitals upon buying the plan. Access right for the plans are as indicated on the face of the Benefit Schedule of the plan. To all intent and purpose, the Benefit Schedule shall form part of the Terms and Conditions and shall be read, interpreted and construed along with these terms and conditions. 

Waiting period means that period of time commencing on the date of commencement of the plans during which an Enrollee is required to wait to be entitled to access any care under the plans. This is a period of 14 days and is in addition to specific waiting periods as stated below. Therefore, a plan purchased becomes active 14 days after completion of registration 

Specific Conditions: Lafiami Health Insurance plan 

• There is a 14 (fourteen) day waiting period from the commencement of cover  

• The Premium computed is payable once annually based on the population. 

• Family premium quoted is for a family of 4 (Principal, Spouse and 2 Children less than 18 years old) 

• The age limit on the Plans is 60 years 

• Prices are indicative and subject to the actual population per plan. 

• There is a 6-month waiting period for Maternity Services while non-maternity related surgery has a waiting period of 6 months 

Right to cancel Policy. Hygeia HMO is at liberty to cancel the cover of any Insured Person(s) who has/have misled it or breached any term of this Agreement, given incorrect, incomplete or misleading information, failed to provide any reasonable information which Hygeia HMO requested, conspired with a third party to obtain undue benefit from this Policy, or submitted a claim which is in any respect fraudulent or unfounded. In any of these circumstances Hygeia HMO shall have the right to cancel the insured persons cover from the date of commencement (without refund of any portion of the unused premium) and recover from him/her any benefit it might have paid/earned in relation to such claim. Similarly, in the case of an instalment payer, the balance instalments shall immediately fall due and become payable to Hygeia HMO by the Enrolees/payer. Hygeia HMO shall have the right to recover all such outstanding premiums against the enrolees/payer. 

Cancellation/Termination at an Enrollees Instance is only available for enrollees making annual payment and possible within the first 30 days of the commencement of the policy. An Enrollee that decides to cancel/terminate this Health Insurance Policy must notify Hygeia HMO in writing and the Enrollee shall be entitled to a refund of the premium paid less (1) any amounts incurred on their behalf as medical and other expenses (2) an administrative charge of 20% of the premium paid. No refund shall apply in case of termination/cancellation made by an Enrollee after 30 days of the commencement of the policy. Provided that for an instalment payer, no refund shall be made by Hygeia HMO of any premium paid prior to the cancellation. 

Cancellation/Termination at Hygeia HMO’s Instance: In the odd event that Hygeia HMO has to terminate the Policy, it shall do so by sending 30 days’ notice by registered letter to an enrollee at their last known address or via electronic means to their known e-mail address indicated to it at any time. In such event, Hygeia HMO will refund to the Enrollee an amount equal to the pro-rata value of their unused premium. Similarly, in the case of an Instalment Payer/Enrolee, the agreement shall immediately cease and the Enrolee shall be liable to pay to Hygeia HMO prorata premium up until the time of termination in the event that such has not been paid. Hygeia shall have the right to recover such premiums from the Enrolee or their authorised representatives. 

Treatment prior to Date of Commencement. Hygeia HMO will not cover or pay for any treatment that was given before an Enrolee’s commencement date of cover (including waiting periods) or after cancellation/termination of cover or during any period for which Hygeia HMO is yet to receive premiums. 

Treatment that is not covered under the Benefit Schedule: Hygeia will not cover or pay for any treatment that is not specifically covered under the Benefit Schedule of the Policy. Hygeia HMO will not cover nor pay for other conditions or procedures which are not specified as covered services in the schedule of benefits for the plans. Similarly, the plans do not cover self-medication or Consultations with unrecognized/un-orthodox consultants, hospitals, family doctors, therapists, dental practitioners or complementary medicines practitioners. In the same vein, complications from such unrecognized/un-orthodox places are not covered under the plans. 

Transferability: The plans are person specific and non-transferable. 

Confidentiality. Hygeia HMO is committed to protecting the information of its Enrollees and it is bound by law and regulatory standards to maintain the privacy of its Enrollees’ medical information and records. Hygeia HMO also holds its employees, providers and consultants and business associates to strict policies and procedures protecting Enrollees information. The Information collected from an Enrollee at enrolment and other transactions would include an Enrollee’s bio-data as well as an Enrollee’s medical information through claims and utilization data submitted from healthcare providers. Hygeia HMO can also access an Enrollee’s medical records in furtherance of its role under the health plans and you hereby consent to our access of your medical records and information accordingly. 

Categorization of Healthcare facilities: Healthcare Providers are categorized by Hygeia HMO for the benefit of ease of access to care by its Enrollees. Hygeia HMO reserves the right to review this categorization from time to time without prior recourse to an Enrollee. This could include (but not limited to) the addition and deletion of healthcare providers from the general list and/or from a specific plan provider list. An Enrollee will however always have access to a number of healthcare facilities within their applicable Hygeia HMO network of Providers. 

Liability. Hygeia HMO shall not be liable for any damages or losses that may arise from an Enrollee’s failure to pay premiums as and when due. Hygeia HMO shall however ensure that its medical service providers provide all covered services in accordance with generally accepted clinical standards. Hygeia HMO shall therefore enter into Standard Agreements with its service providers for the protection of the beneficiaries/Enrollees. 

Payment 

• Premiums are due annually and the full annual premium is established/crystallises at the start of the Annual cover or a renewal period thereof. Unless payment by instalment was approved at commencement of cover or any renewal period thereof, the principal enrollee must pay the full premium amount due to Hygeia HMO at the beginning of the policy period for the Enrolees to be covered prior to commencement of cover. This notwithstanding, and irrespective of the agreed payment by instalment, the enrollee shall be liable to pay the full premium in the event of an early termination of the cover. 

• Where payment is by monthly instalment, the enrollee shall pay the first instalment at inception with the subsequent instalments payable not later than the last day of each preceding month and where Hygeia HMO does not receive payment within the agreed timelines, Hygeia HMO shall be at liberty to suspend care to the enrollee. 

• An enrollee who defaults on instalment payment shall first pay all outstanding monthly instalment as well as the instalment due for the new month that will begin to run, before reinstatement of care. Care shall be reinstated with 14 days waiting period and the   cover shall still run for the original period of one year without extension i.e., based on the commencement date of the plan irrespective of the suspension during the year.  

• For all intent and purpose, Hygeia HMO shall be at liberty to modify the payment process and information at any time, and notify the enrollee of the new process. Provided however that only payments acknowledged by Hygeia HMO shall be deemed valid. 

Refunds 

Enrollees are required to access medically necessary care within Hygeia HMO’s network of Providers alone and not pay out of pocket for covered services. In the odd event that an enrollee has to pay out of pocket, this only has to be in an emergency situation as qualified by a medical practitioner without influence of the enrolee and only within Hygeia. The refund will be made by Hygeia HMO upon the enrollee providing the following documents within 30 days of encounter: (1) copy of medical report from the health care practitioner indicating history of the medical condition, diagnosis and treatment administered, (2) Original Receipt for having made payment indicating the costs separately for consultation, each investigation, each procedure and each Drug and the quantity dispensed. 

All refunds will be made only into the enrollees designated account based only on medical necessity as might be reviewed by Hygeia HMO’s in-house medical practitioners and only at Hygeia HMO’s designated/customary rate irrespective of the cost of care. Also, refunds are only applicable where same is received before receipt by Hygeia HMO of the notice to terminate or expiration of a plan. 

Supply of drugs & medication – all enrollees are covered for drugs recommended in the course of their treatment for covered services as defined in the plan benefit except for excluded items. As a standard, enrollees shall be prescribed generic drugs. except where no generic option exists, in which case, prior approval will be sought by the provider to dispense branded medication. 

In the event that the provider or enrollee prefers a branded option where a generic option is available, such option may be paid for directly by the enrollee to the provider. Kindly note that where the provider does not maintain a stock of generic medications, a prescription should be collected and the generic medication taken from a pharmacy for which Hygeia HMO will be responsible. 

Referral: All Referrals for access to care will be to only Hygeia HMO network Providers alone. Any referrals to an out of network Provider shall be borne by the enrolee and not eligible for refunds. 

Notices or demands. Any notice or demand required to be given under this Agreement, or given in connection with it, shall be in writing and shall be given by electronic means. Should the Enrollee require or where Hygeia HMO deems same expedient, such notice may also be issued in hard copy and delivered by personal delivery or courier service delivery to the last known address of the other party. Changes in address has to be communicated to the other party otherwise, notifications will continue to be delivered to the last known address and remain legally enforceable.  

Review: Hygeia HMO shall be at liberty to review the terms and conditions herein or as contained in the benefit schedule of a plan, at any time without prior recourse to the enrollee provided however that such amendment can only take effect at renewal of a subsisting term of an enrolee’s plan. The plan shall renew automatically upon the payment of the appropriate premium under the terms and conditions as well as benefits schedule applicable at renewal and shall subsist for another year. Consequently, only the current years Benefit Schedule as well as terms and Conditions presented by Hygeia HMO shall be applicable during any given one-year term. The enrolee or their Authorised Representative is at liberty to request for the current year’s benefit schedule as well as the Terms and Conditions should they wish.   

Consent and Understanding 

By signing this form, I the under listed Enrolee and/or Authorised Representative thereof understands that  

(1) Hygeia HMO Limited is not a hospital. I affirm that the information provided is entered correctly and truthfully. I have read and understood the terms and conditions herein and I confirm that I am aware and have read the content of the schedule of benefits; accordingly, I agree to be bound by both the Terms and Conditions and the Schedule of Benefits. 

(2) Hygeia HMO lawfully collates and processes data including but not limited to name, Sex, address, spouse, children, telephone number, email address, date of birth, national identification number, diagnosis, treatments, medications, treatment guidelines etc. for the administration and provision of access to healthcare to Enrolees through its network of health care providers. Data collected is solely processed by Hygeia HMO staff and legally appointed third parties under its network. All collected data are stored and transmitted through secure electronic and physical channels to Hygeia’s agents, third parties and Providers who are all contractually bound to process all data received with the highest standards of confidentiality. Data collected will be held as long as is necessary to implement, administer and manage access to care and retrieval of information under the Hygeia HMO network or as stipulated by necessary Regulation. An Enrolee may however request for his/her data to be deleted upon complete termination of the health insurance plan after a period of One year has lapsed since termination. 

(3) By acquiring this health insurance plan, I hereby consent explicitly and completely to the collection, use, processing and transfer, in hardcopy, electronic means or other form, of my personal data as requested and provided to Hygeia HMO.  I also authorize the transfer of my/our data to Health Care Providers and such other agents and third parties as Hygeia HMO may deem fit in furtherance to their role as Administrators and for the facilitation of access to care under the Policy/plan purchased and understand that I/we are at liberty to refuse or withdraw my/our consent. 

FORCE MAJEURE 

Neither Party shall be in breach of these Terms or otherwise liable to the other Party for any failure to perform or delay in the performance of the whole or part of its obligations under this Agreement which is caused by a Force Majeure event for as long as the Force Majeure event continues, provided that the Party affected by the Force Majeure event has within 24 hours after the occurrence of the Force Majeure event notified the other Party of the occurrence of the Force Majeure event. Such Party shall be excused from performance hereunder for so long as such causes, circumstances or events shall continue to prevent or delay such performance but not later than 21 days thereafter, after which the Agreement shall terminate. 

For purpose of this Agreement, Force Majeure refers to any event beyond the reasonable control of the Parties, which by exercise of due diligence neither party is able to overcome and which makes a Party’s performance of its obligations hereunder impossible or as impracticable as reasonably to be considered impossible under the circumstances. Such obligations include but are not limited to industrial dispute, strikes, riots, floods, fires, unnecessary hike in Provider Tariff, accidents, earthquakes, explosions, wars, hostilities, civil commotion, pandemics, epidemics, acts of God, and acts of directives of government or government authority.  

In circumstances where Hygeia HMO is the affected party, the enrollee shall not be relieved from any obligation to make payments under this Agreement that are properly due and payable prior to receipt of notice of the Force Majeure eve