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FIRST’ EXPAT//RELAIS’ EXPAT
// INFORMATION BOOKLET SERVING AS THE GENERAL TERMS & CONDITIONS
// INFORMATION BOOKLET SERVING AS THE GENERAL TERMS & CONDITIONS
5
2. / DEFINITIONS OF HEALTHCARE BENEFITS
You will find below the definitions of the terms used in this document (Information Booklet serving as the General Terms &
Conditions).
Accident: Any bodily injury not intended by the person who suffered it, resulting from sudden, unpredictable action with an external
cause. It is the Insured member’s responsibility to provide proof of the Accident and the direct cause-and-effect relationship between
it and the costs incurred.
Acupuncture: Branch of traditional Chinese medicine which consists of inserting needles into specific points on the patient’s body
to relieve various Illnesses or to create an analgesic effect.
Administrator of the plan (administrating organization): Refers to MSH International, a French insurance broker registered with
ORIAS under number 07 002 751, who manages the ASFE plans.
Aggregate limit (on healthcare benefits): The Benefits schedule for the plan stipulates 2 types of benefit limits:
- the Aggregate limit on healthcare benefits refers to the maximum amount the Insurer will pay in respect of all healthcare
benefits (hospitalization & Routine healthcare as well as the Dental and Vision options and Maternity, if selected), per recipient
of the healthcare per Insurance year, for the selected level of healthcare coverage;
- in addition to this Aggregate limit, there are also, for certain benefits, (Routine healthcare + Vision/Dental options and
Maternity) or certain treatments or procedures (consultations, Vaccinations, lenses, frames, etc.) upper limits which are
expressed as a value and/or as a number of days or number of treatments or procedures/sessions which are applied either
per Insurance year, for the life of the plan, per treatment, per procedure or consultation or per day. All upper limits apply per
recipient of the healthcare and per Insurance year, unless otherwise stated in the Benefits schedule.
Alternative medicine: In the plan this refers to: Homeopathy, Acupuncture and Traditional Chinese medicine.
Annual out-of-pocket maximum: The annual out-of-pocket maximum is the maximum amount of cost-sharing that you will have
to pay during the Insurance year.
Annual renewal date: Each anniversary of the effective date of enrollment in the plan.
Application for coverage: Refers to the document confirming the Member’s application for coverage under the plan, and any other
statement made by the primary Member for themselves or for any Dependents listed on the Application for coverage.
Benefits schedule: Document indicating, in respect of the level of healthcare coverage selected by the Member for themselves and
any Dependents, details of the benefits provided under the plan, showing the upper limits, limits on the number of treatments or
procedures, consultations and/or days covered for a given period of time and the Waiting periods, Deductibles, Cost-sharing, Annual
out-of-pocket maximum or Co-payments which apply to them.
Bone density test: Medical examination to measure bone density by assessing bone mineral content (mainly calcium), which is most
commonly performed using a special type of x-ray of the lumbar spine and/or femoral neck. It is used in screening for osteoporosis.
Cancelation period: A Cancelation period is granted to a person who has just enrolled in an insurance plan with optional
membership. A Member may reverse their decision to enroll in an insurance plan for a period of 14 calendar days from the date on
which their Certificate of enrollment is sent out, without having to provide reasons or pay penalties (see section 5.2/ Life of your plan
p.32 in the chapter CANCELING YOUR MEMBERSHIP BEFORE IT TAKES EFFECT: THE CANCELATION PERIOD.
Certificate of enrollment: Single document, issued only at the time of enrollment confirming the Member’s enrollment in the plan
and specifying, as well as the name and address of the Member, and those of any insured Dependents, the Effective date of
enrollment, the benefits selected, the Selected coverage zone, the chosen Deductible and the corresponding Premium. The Certificate
of enrollment corresponds to the special conditions of enrollment in the plan.
Certificate of insurance: Document whose purpose is to serve as proof of insurance cover for the person presenting it. It contains
the following information: name of the Member and any Dependents, Effective date of enrollment in the plan, number and type of
enrollment selected, Insurer of the plan, benefits, Selected coverage zone and chosen Deductible.
Certificate of termination: Document provided to confirm the end of membership of the plan. This certificate is usually required by
the Member’s new health insurer if they switch to another health insurance plan.
CFE: Caisse des Français de l’Etranger, French Social Security body whose purpose and mission is to insure expatriates worldwide.
Childbirth complications: Term used to refer to the following conditions that may occur during childbirth and for which an obstetric
procedure is essential: fetal distress during labor, retained placenta and postpartum hemorrhage. They also include C-section if it is
Medically required. Childbirth complications are only covered if the person receiving the care has Maternity coverage (option
commercialized as ‘HEALTH+CHILD’).
Childbirth without complications: This refers to childbirth not requiring any additional Emergency surgery: fetal distress during
labor, retained placenta and postpartum hemorrhage. C-sections which are not Medically required will be classed as Childbirth
without complications.
Chiropractic: Therapeutic approach which aims to treat a variety of conditions by manipulation.
Chronic conditions: These are conditions whose severity and/or long-term nature require prolonged treatment and costly therapy.
The list of chronic conditions is defined under Article D. 322-1 of the French Social Security Code. This list is provided on page 80 as
an appendix.
Common-law marriage: Union characterized by a continuous, stable, shared life between two persons of the opposite or same sex
who are living together as a couple.
Common-law spouse: Person under the age of 71 on the date of enrollment, who is living in a Common-law marriage with the
Member, whether or not they are in paid employment, if and only if: the Member and their Common-law spouse share the same
home and are free from any other ties of a similar nature (i.e. both partners are single, widowed or divorced and are not bound by a
civil partnership).
If there are several common-law spouses, only the eldest will be recognized.
2. / DEFINITIONS OF HEALTHCARE BENEFITS
You will find below the definitions of the terms used in this document (Information Booklet serving as the General Terms &
Conditions).
Accident: Any bodily injury not intended by the person who suffered it, resulting from sudden, unpredictable action with an external
cause. It is the Insured member’s responsibility to provide proof of the Accident and the direct cause-and-effect relationship between
it and the costs incurred.
Acupuncture: Branch of traditional Chinese medicine which consists of inserting needles into specific points on the patient’s body
to relieve various Illnesses or to create an analgesic effect.
Administrator of the plan (administrating organization): Refers to MSH International, a French insurance broker registered with
ORIAS under number 07 002 751, who manages the ASFE plans.
Aggregate limit (on healthcare benefits): The Benefits schedule for the plan stipulates 2 types of benefit limits:
- the Aggregate limit on healthcare benefits refers to the maximum amount the Insurer will pay in respect of all healthcare
benefits (hospitalization & Routine healthcare as well as the Dental and Vision options and Maternity, if selected), per recipient
of the healthcare per Insurance year, for the selected level of healthcare coverage;
- in addition to this Aggregate limit, there are also, for certain benefits, (Routine healthcare + Vision/Dental options and
Maternity) or certain treatments or procedures (consultations, Vaccinations, lenses, frames, etc.) upper limits which are
expressed as a value and/or as a number of days or number of treatments or procedures/sessions which are applied either
per Insurance year, for the life of the plan, per treatment, per procedure or consultation or per day. All upper limits apply per
recipient of the healthcare and per Insurance year, unless otherwise stated in the Benefits schedule.
Alternative medicine: In the plan this refers to: Homeopathy, Acupuncture and Traditional Chinese medicine.
Annual out-of-pocket maximum: The annual out-of-pocket maximum is the maximum amount of cost-sharing that you will have
to pay during the Insurance year.
Annual renewal date: Each anniversary of the effective date of enrollment in the plan.
Application for coverage: Refers to the document confirming the Member’s application for coverage under the plan, and any other
statement made by the primary Member for themselves or for any Dependents listed on the Application for coverage.
Benefits schedule: Document indicating, in respect of the level of healthcare coverage selected by the Member for themselves and
any Dependents, details of the benefits provided under the plan, showing the upper limits, limits on the number of treatments or
procedures, consultations and/or days covered for a given period of time and the Waiting periods, Deductibles, Cost-sharing, Annual
out-of-pocket maximum or Co-payments which apply to them.
Bone density test: Medical examination to measure bone density by assessing bone mineral content (mainly calcium), which is most
commonly performed using a special type of x-ray of the lumbar spine and/or femoral neck. It is used in screening for osteoporosis.
Cancelation period: A Cancelation period is granted to a person who has just enrolled in an insurance plan with optional
membership. A Member may reverse their decision to enroll in an insurance plan for a period of 14 calendar days from the date on
which their Certificate of enrollment is sent out, without having to provide reasons or pay penalties (see section 5.2/ Life of your plan
p.32 in the chapter CANCELING YOUR MEMBERSHIP BEFORE IT TAKES EFFECT: THE CANCELATION PERIOD.
Certificate of enrollment: Single document, issued only at the time of enrollment confirming the Member’s enrollment in the plan
and specifying, as well as the name and address of the Member, and those of any insured Dependents, the Effective date of
enrollment, the benefits selected, the Selected coverage zone, the chosen Deductible and the corresponding Premium. The Certificate
of enrollment corresponds to the special conditions of enrollment in the plan.
Certificate of insurance: Document whose purpose is to serve as proof of insurance cover for the person presenting it. It contains
the following information: name of the Member and any Dependents, Effective date of enrollment in the plan, number and type of
enrollment selected, Insurer of the plan, benefits, Selected coverage zone and chosen Deductible.
Certificate of termination: Document provided to confirm the end of membership of the plan. This certificate is usually required by
the Member’s new health insurer if they switch to another health insurance plan.
CFE: Caisse des Français de l’Etranger, French Social Security body whose purpose and mission is to insure expatriates worldwide.
Childbirth complications: Term used to refer to the following conditions that may occur during childbirth and for which an obstetric
procedure is essential: fetal distress during labor, retained placenta and postpartum hemorrhage. They also include C-section if it is
Medically required. Childbirth complications are only covered if the person receiving the care has Maternity coverage (option
commercialized as ‘HEALTH+CHILD’).
Childbirth without complications: This refers to childbirth not requiring any additional Emergency surgery: fetal distress during
labor, retained placenta and postpartum hemorrhage. C-sections which are not Medically required will be classed as Childbirth
without complications.
Chiropractic: Therapeutic approach which aims to treat a variety of conditions by manipulation.
Chronic conditions: These are conditions whose severity and/or long-term nature require prolonged treatment and costly therapy.
The list of chronic conditions is defined under Article D. 322-1 of the French Social Security Code. This list is provided on page 80 as
an appendix.
Common-law marriage: Union characterized by a continuous, stable, shared life between two persons of the opposite or same sex
who are living together as a couple.
Common-law spouse: Person under the age of 71 on the date of enrollment, who is living in a Common-law marriage with the
Member, whether or not they are in paid employment, if and only if: the Member and their Common-law spouse share the same
home and are free from any other ties of a similar nature (i.e. both partners are single, widowed or divorced and are not bound by a
civil partnership).
If there are several common-law spouses, only the eldest will be recognized.
6
Contracting association: ASFE. Legal entity having purchased the plan for the benefit of its Members and which agrees to fulfill the
corresponding obligations.
Co-payment: Fixed amount specified in the plan per treatment, procedure or visit which is payable by the Member and their
Dependents. It is applicable per person.
Cost-sharing: Cost-sharing is the percentage of each claim that is not covered by your insurance plan.
Country of nationality: Any country for which the Insured member holds a valid passport and of which they are a citizen, national
or subject, as specified in the Application for coverage.
Date of termination: Date on which the benefits provided under the insurance plan come to an end, on the initiative of the Member,
the Insurer or the Contracting association (see section 5.2/ Life of your plan p.32 in the chapter CESSATION OF MEMBERSHIP AND
END OF COVERAGE (right of withdrawal and termination)).
Deductible: Refers to the amount payable by the Member and any Dependents which is deducted from the reimbursable amount. It
is applicable per person and per Insurance year. If this option is selected it will be specified on the Certificate of enrollment.
Dental surgery: Refers to any Dental surgical procedure with anesthesia including dental extraction and bone or gum grafts.
Dentures and dental implants: Refers to appliances used for fixed reconstruction or repair, bridges, crowns, dentures and implants,
inlays, onlays, inlay cores and any auxiliary treatment required.
Dependent: The following are classed as dependents if they are enrolled in the plan: the Member’s Spouse, Civil partner or Common-
law spouse and Dependent children as defined in this section.
Dependent children: Children of the Member, their Spouse, Partner or Common-law spouse:
Under a FIRST’EXPAT+ plan (1st Euro/Dollar): children under the age of 26 will be considered dependent if they are in full-
time education and are covered under the plan
Under a RELAIS’EXPAT+ plan (in addition to CFE benefits): children under the age of 20 will be considered dependent if
they are in full-time education and are covered under the plan
In all cases, for children over the age of 18 who are in in full-time education and are covered under the plan as Dependents,
a school certificate is required at the time of enrollment and subsequently at the beginning of each academic year.
Dietitian: A qualified health professional specializing in nutrition and food who is officially registered, qualified and recognized in
the country in which they practice and who has the additional experience and qualifications required to deliver this service.
Doctor: Health professional holding a degree of Doctor of Medicine who is authorized to practice medicine under the laws of the
country where the treatment is administered, within the limits of the license they have been granted and who is not a family member
of the person covered under this plan.
Duration of membership: Period of coverage under the plan from the effective date of enrollment shown on the certificate of
enrollment to the date of termination of membership as set out under section 5.2/ Life of your plan p.32 in the chapter CESSATION
OF MEMBERSHIP AND END OF COVERAGE (right of withdrawal and termination).
Effective date of benefits: Date specified on the Certificate of enrollment on which the benefits provided under the plan take effect,
after application of the Waiting periods.
Effective date of enrollment: Date specified on the Certificate of enrollment on which the benefits provided under the plan take
effect.
Emergency: Refers to the medical condition or symptoms resulting from an Illness or injury occurring suddenly and which clearly
requires immediate treatment, usually within 24 hours of onset, without which there would be a risk of endangering the health of
the affected person.
Emergency dental and vision care with hospitalization: Term referring to extremely urgent dental and vision care dispensed
following a serious Accident or the sudden onset of an infection requiring hospitalization. Treatment must be administered within 24
hours of the Accident or infection. This benefit does not cover routine Dental surgery, routine dental care, Dentures, routine vision
care, vision correction, laser vision correction and Orthodontics and Periodontics. These treatments are covered under the optional
Dental/Vision benefits.
Emergency dental and vision care without hospitalization: Term referring to extremely urgent dental and vision care not
requiring hospitalization but which must be administered as an Emergency to relieve pain which is hard to tolerate. This benefit does
not cover routine Dental surgery, routine dental care, Dentures, routine vision care, vision correction, laser vision correction and
Orthodontics and Periodontics. These treatments are covered under the optional Dental/Vision benefits.
Emergency hospitalization: Treatment administered following admission to a Hospital or medical center as a result of the onset of
a sudden and unexpected health concern, following an Illness, Accident, infection, etc.
Emergency treatment outside the coverage zone: Refers to Emergency treatment received in a higher zone than the Selected
coverage zone, during a trip for the purposes of either business or leisure.
Coverage is acquired for a maximum of 60 days per trip and is also limited to the Aggregate limit and only covers treatment required
in the event of an Accident or the onset of a sudden, unexpected and unforeseen Illness, requiring surgery or Medical treatment that
cannot wait until repatriation to the Main country of residence or the worsening of a serious Illness representing an immediate and
serious danger to the health of the Member and/or their Dependents. Treatment dispensed by a General practitioner or a Specialist
must begin within 24 hours of the event which triggered the claim.
The following are therefore not covered by this benefit: non-urgent therapeutic treatment which did not result from an Accident or
unforeseen Illness requiring surgery, or Medical treatment that cannot wait until repatriation to the Main country of residence or the
worsening of a serious Illness representing an immediate and serious danger to the health of the Member and follow-up care, even
in cases where the Member or their Dependents were not able to travel to a country within their Selected coverage zone. Costs
related to Pregnancy, Maternity, childbirth or any other Complication during Pregnancy or childbirth are also excluded from the
benefit. It is recommended that Members and any Dependents contact the Administrator, MSH International, if trips of more than 60
days are planned outside the Selected coverage zone.
Excluded countries: As a result of events (civil or foreign war, insurrection, etc.) which may be taking place there and, in all
circumstances, in accordance with the classification of at-risk countries published by the French Ministry of Foreign Affairs, coverage
Contracting association: ASFE. Legal entity having purchased the plan for the benefit of its Members and which agrees to fulfill the
corresponding obligations.
Co-payment: Fixed amount specified in the plan per treatment, procedure or visit which is payable by the Member and their
Dependents. It is applicable per person.
Cost-sharing: Cost-sharing is the percentage of each claim that is not covered by your insurance plan.
Country of nationality: Any country for which the Insured member holds a valid passport and of which they are a citizen, national
or subject, as specified in the Application for coverage.
Date of termination: Date on which the benefits provided under the insurance plan come to an end, on the initiative of the Member,
the Insurer or the Contracting association (see section 5.2/ Life of your plan p.32 in the chapter CESSATION OF MEMBERSHIP AND
END OF COVERAGE (right of withdrawal and termination)).
Deductible: Refers to the amount payable by the Member and any Dependents which is deducted from the reimbursable amount. It
is applicable per person and per Insurance year. If this option is selected it will be specified on the Certificate of enrollment.
Dental surgery: Refers to any Dental surgical procedure with anesthesia including dental extraction and bone or gum grafts.
Dentures and dental implants: Refers to appliances used for fixed reconstruction or repair, bridges, crowns, dentures and implants,
inlays, onlays, inlay cores and any auxiliary treatment required.
Dependent: The following are classed as dependents if they are enrolled in the plan: the Member’s Spouse, Civil partner or Common-
law spouse and Dependent children as defined in this section.
Dependent children: Children of the Member, their Spouse, Partner or Common-law spouse:
Under a FIRST’EXPAT+ plan (1st Euro/Dollar): children under the age of 26 will be considered dependent if they are in full-
time education and are covered under the plan
Under a RELAIS’EXPAT+ plan (in addition to CFE benefits): children under the age of 20 will be considered dependent if
they are in full-time education and are covered under the plan
In all cases, for children over the age of 18 who are in in full-time education and are covered under the plan as Dependents,
a school certificate is required at the time of enrollment and subsequently at the beginning of each academic year.
Dietitian: A qualified health professional specializing in nutrition and food who is officially registered, qualified and recognized in
the country in which they practice and who has the additional experience and qualifications required to deliver this service.
Doctor: Health professional holding a degree of Doctor of Medicine who is authorized to practice medicine under the laws of the
country where the treatment is administered, within the limits of the license they have been granted and who is not a family member
of the person covered under this plan.
Duration of membership: Period of coverage under the plan from the effective date of enrollment shown on the certificate of
enrollment to the date of termination of membership as set out under section 5.2/ Life of your plan p.32 in the chapter CESSATION
OF MEMBERSHIP AND END OF COVERAGE (right of withdrawal and termination).
Effective date of benefits: Date specified on the Certificate of enrollment on which the benefits provided under the plan take effect,
after application of the Waiting periods.
Effective date of enrollment: Date specified on the Certificate of enrollment on which the benefits provided under the plan take
effect.
Emergency: Refers to the medical condition or symptoms resulting from an Illness or injury occurring suddenly and which clearly
requires immediate treatment, usually within 24 hours of onset, without which there would be a risk of endangering the health of
the affected person.
Emergency dental and vision care with hospitalization: Term referring to extremely urgent dental and vision care dispensed
following a serious Accident or the sudden onset of an infection requiring hospitalization. Treatment must be administered within 24
hours of the Accident or infection. This benefit does not cover routine Dental surgery, routine dental care, Dentures, routine vision
care, vision correction, laser vision correction and Orthodontics and Periodontics. These treatments are covered under the optional
Dental/Vision benefits.
Emergency dental and vision care without hospitalization: Term referring to extremely urgent dental and vision care not
requiring hospitalization but which must be administered as an Emergency to relieve pain which is hard to tolerate. This benefit does
not cover routine Dental surgery, routine dental care, Dentures, routine vision care, vision correction, laser vision correction and
Orthodontics and Periodontics. These treatments are covered under the optional Dental/Vision benefits.
Emergency hospitalization: Treatment administered following admission to a Hospital or medical center as a result of the onset of
a sudden and unexpected health concern, following an Illness, Accident, infection, etc.
Emergency treatment outside the coverage zone: Refers to Emergency treatment received in a higher zone than the Selected
coverage zone, during a trip for the purposes of either business or leisure.
Coverage is acquired for a maximum of 60 days per trip and is also limited to the Aggregate limit and only covers treatment required
in the event of an Accident or the onset of a sudden, unexpected and unforeseen Illness, requiring surgery or Medical treatment that
cannot wait until repatriation to the Main country of residence or the worsening of a serious Illness representing an immediate and
serious danger to the health of the Member and/or their Dependents. Treatment dispensed by a General practitioner or a Specialist
must begin within 24 hours of the event which triggered the claim.
The following are therefore not covered by this benefit: non-urgent therapeutic treatment which did not result from an Accident or
unforeseen Illness requiring surgery, or Medical treatment that cannot wait until repatriation to the Main country of residence or the
worsening of a serious Illness representing an immediate and serious danger to the health of the Member and follow-up care, even
in cases where the Member or their Dependents were not able to travel to a country within their Selected coverage zone. Costs
related to Pregnancy, Maternity, childbirth or any other Complication during Pregnancy or childbirth are also excluded from the
benefit. It is recommended that Members and any Dependents contact the Administrator, MSH International, if trips of more than 60
days are planned outside the Selected coverage zone.
Excluded countries: As a result of events (civil or foreign war, insurrection, etc.) which may be taking place there and, in all
circumstances, in accordance with the classification of at-risk countries published by the French Ministry of Foreign Affairs, coverage
7
may be excluded for certain countries or zones to which travel is classed by this Ministry as highly inadvisable (red zone) or inadvisable
(orange zone).
Fertility treatment: Fertility treatment means all methods of medically assisted reproduction (MAR), also known as medically
assisted procreation (MAP), enabling a couple diagnosed as infertile to have a child. The methods covered under the plan are: in vitro
fertilization (IVF), artificial insemination, hormone treatments and tubal surgery.
General practitioner: A General practitioner is responsible for the long-term monitoring, well-being and primary general medical
care of a community. The care provided is not limited to groups of Illnesses related to a single organ, age group or gender. The
General practitioner is often consulted to diagnose symptoms before treating the condition or referring the patient to a Specialist.
Health check-ups: Examinations or Laboratory tests carried out at any time in life in the absence of any apparent clinical symptoms
(please refer to the healthcare benefits schedule to find the list of examinations covered under this benefit).
Home country: Country for which the Insured member has a valid passport and/or to which they would wish to be repatriated if
necessary.
Home hospitalization: Care delivered in the patient's home as an alternative to conventional hospitalization with at least one visit
per day from a nurse, subject to the agreement of the medical department/prior approval.
Homeopathy: Therapeutic method consisting of prescribing a highly diluted and energized form of a substance capable of producing
similar complaints to those experienced by the patient.
Hospital: Refers to a care facility or a medical institution which is registered or approved as a medical or surgical Hospital under local
regulations in the country in which it is located and where the Insured member receives daily treatment or is under the supervision
of a Doctor or a qualified nurse. The following are not classed as Hospitals: wellness and fitness centers, spas, nursing homes,
retirement homes and convalescent homes.
(Hospital) day care: See under Outpatient hospitalization.
Illness: Any deterioration in the state of health certified by a competent medical authority.
Increased health risk: Persons with an Increased health risk are those who are sick, who have been sick or are particularly
susceptible to being sick and who present a risk of Illness (morbidity) or death (mortality) greater than that of the average person of
the same age. These individuals cannot therefore be insured under the standard terms and conditions.
Information booklet serving as the general terms & conditions: This document defining the benefits, exclusions and conditions
of use of the insurance plan (including all information on reimbursement procedures). It should be read in conjunction with the
Certificate of enrollment and the Benefits schedule.
Insurance year: The Insurance year covers the period from the Effective date of Enrollment in the plan until the 365th day following
this date, with automatic renewal on each anniversary date.
Insured member or dependent: Refers generically to the Member and other persons covered under their plan. They receive the
Benefits provided by the Insurer in respect of claims made and covered under the plan. In this plan, insured members/ dependents
are also referred to as “You”.
Insurer: For the purposes of the plan, Groupama Gan Vie, a company regulated by the French Insurance code, is the Insurer of the
benefits provided under the plan.
Intensive care: Refers to a specialized hospital department the purpose of which is to care for patients in a critical condition, that is,
who are presenting with failure of one or more of their vital functions, or who are at risk of developing severe complications. The
service has highly specialized technical resources. These are in continuous use by a multidisciplinary team in order to identify, prevent
and correct acute and presumably reversible imbalances related to the underlying condition (Illness, surgery, trauma and
intoxication). This type of facility includes Intensive care units, critical care units, intensive therapeutic services units or intensive
treatment units.
Internal and external surgical and medical prostheses and devices: Refers to any appliance, prosthesis or device required or
used during surgery or considered to be Medically required for the treatment.
Laboratory tests: Examinations, including x-rays and blood tests, carried out to determine the origin of the symptoms presented or
to monitor the status of the condition.
Local transfer by ambulance: Refers to transportation by ambulance of a patient, required in cases of Medical necessity or
Emergency, to the Hospital or the nearest licensed medical facility best suited to the situation. This service is provided by the
Assistance company.
Main country of residence/country of expatriation: Country of residence indicated by the Insured member in their Application for
coverage and shown on their Certificate of enrollment, or confirmed in writing to the Insurer during the life of the plan, in which the
primary Member and any Dependents reside for at least six months of the year. The country specified in this way must correspond
to the Main country of residence recognized by the authorities of that country (in particular, the tax authorities). The Main country of
residence is used to determine the minimum Coverage zone which needs to be selected on enrollment in the plan.
Maternity: Non-pathological Pregnancy, childbirth and its consequences. Maternity is classed neither as an Illness nor an Accident.
Medical advisor: Doctor working for a public or private organization (insurance company, health insurance fund, etc.) who is
responsible for providing a medical opinion on the cases submitted to them.
Medical (health) questionnaire: In the context of an application for coverage under the insurance plan, a set of questions on the
health of the Member and any Dependents which enables the Insurer’s Medical advisor to assess their state of health and set the
terms of the insurance. In case of increased risk for the Insurer, the completion of the Medical health questionnaire may result in an
additional Premium being applied to the Member and/or one of their Dependents, an exclusion from one or more of the benefits or
a total refusal of the Application for coverage under the plan. The Medical Questionnaire is valid for 4 months.
Medical imaging: Medical imaging is used for clinical purposes in order to provide a diagnosis or propose a treatment. There are
several Medical imaging techniques: radiology, ultrasound, magnetic resonance imaging (MRI), endoscopy, scanner, laser,
tomography, etc.
may be excluded for certain countries or zones to which travel is classed by this Ministry as highly inadvisable (red zone) or inadvisable
(orange zone).
Fertility treatment: Fertility treatment means all methods of medically assisted reproduction (MAR), also known as medically
assisted procreation (MAP), enabling a couple diagnosed as infertile to have a child. The methods covered under the plan are: in vitro
fertilization (IVF), artificial insemination, hormone treatments and tubal surgery.
General practitioner: A General practitioner is responsible for the long-term monitoring, well-being and primary general medical
care of a community. The care provided is not limited to groups of Illnesses related to a single organ, age group or gender. The
General practitioner is often consulted to diagnose symptoms before treating the condition or referring the patient to a Specialist.
Health check-ups: Examinations or Laboratory tests carried out at any time in life in the absence of any apparent clinical symptoms
(please refer to the healthcare benefits schedule to find the list of examinations covered under this benefit).
Home country: Country for which the Insured member has a valid passport and/or to which they would wish to be repatriated if
necessary.
Home hospitalization: Care delivered in the patient's home as an alternative to conventional hospitalization with at least one visit
per day from a nurse, subject to the agreement of the medical department/prior approval.
Homeopathy: Therapeutic method consisting of prescribing a highly diluted and energized form of a substance capable of producing
similar complaints to those experienced by the patient.
Hospital: Refers to a care facility or a medical institution which is registered or approved as a medical or surgical Hospital under local
regulations in the country in which it is located and where the Insured member receives daily treatment or is under the supervision
of a Doctor or a qualified nurse. The following are not classed as Hospitals: wellness and fitness centers, spas, nursing homes,
retirement homes and convalescent homes.
(Hospital) day care: See under Outpatient hospitalization.
Illness: Any deterioration in the state of health certified by a competent medical authority.
Increased health risk: Persons with an Increased health risk are those who are sick, who have been sick or are particularly
susceptible to being sick and who present a risk of Illness (morbidity) or death (mortality) greater than that of the average person of
the same age. These individuals cannot therefore be insured under the standard terms and conditions.
Information booklet serving as the general terms & conditions: This document defining the benefits, exclusions and conditions
of use of the insurance plan (including all information on reimbursement procedures). It should be read in conjunction with the
Certificate of enrollment and the Benefits schedule.
Insurance year: The Insurance year covers the period from the Effective date of Enrollment in the plan until the 365th day following
this date, with automatic renewal on each anniversary date.
Insured member or dependent: Refers generically to the Member and other persons covered under their plan. They receive the
Benefits provided by the Insurer in respect of claims made and covered under the plan. In this plan, insured members/ dependents
are also referred to as “You”.
Insurer: For the purposes of the plan, Groupama Gan Vie, a company regulated by the French Insurance code, is the Insurer of the
benefits provided under the plan.
Intensive care: Refers to a specialized hospital department the purpose of which is to care for patients in a critical condition, that is,
who are presenting with failure of one or more of their vital functions, or who are at risk of developing severe complications. The
service has highly specialized technical resources. These are in continuous use by a multidisciplinary team in order to identify, prevent
and correct acute and presumably reversible imbalances related to the underlying condition (Illness, surgery, trauma and
intoxication). This type of facility includes Intensive care units, critical care units, intensive therapeutic services units or intensive
treatment units.
Internal and external surgical and medical prostheses and devices: Refers to any appliance, prosthesis or device required or
used during surgery or considered to be Medically required for the treatment.
Laboratory tests: Examinations, including x-rays and blood tests, carried out to determine the origin of the symptoms presented or
to monitor the status of the condition.
Local transfer by ambulance: Refers to transportation by ambulance of a patient, required in cases of Medical necessity or
Emergency, to the Hospital or the nearest licensed medical facility best suited to the situation. This service is provided by the
Assistance company.
Main country of residence/country of expatriation: Country of residence indicated by the Insured member in their Application for
coverage and shown on their Certificate of enrollment, or confirmed in writing to the Insurer during the life of the plan, in which the
primary Member and any Dependents reside for at least six months of the year. The country specified in this way must correspond
to the Main country of residence recognized by the authorities of that country (in particular, the tax authorities). The Main country of
residence is used to determine the minimum Coverage zone which needs to be selected on enrollment in the plan.
Maternity: Non-pathological Pregnancy, childbirth and its consequences. Maternity is classed neither as an Illness nor an Accident.
Medical advisor: Doctor working for a public or private organization (insurance company, health insurance fund, etc.) who is
responsible for providing a medical opinion on the cases submitted to them.
Medical (health) questionnaire: In the context of an application for coverage under the insurance plan, a set of questions on the
health of the Member and any Dependents which enables the Insurer’s Medical advisor to assess their state of health and set the
terms of the insurance. In case of increased risk for the Insurer, the completion of the Medical health questionnaire may result in an
additional Premium being applied to the Member and/or one of their Dependents, an exclusion from one or more of the benefits or
a total refusal of the Application for coverage under the plan. The Medical Questionnaire is valid for 4 months.
Medical imaging: Medical imaging is used for clinical purposes in order to provide a diagnosis or propose a treatment. There are
several Medical imaging techniques: radiology, ultrasound, magnetic resonance imaging (MRI), endoscopy, scanner, laser,
tomography, etc.
8
Medical network: Means all Hospitals or associated care facilities and healthcare practitioners officially listed by your plan
Administrator (MSH International) or by the service partners selected by them (such as UnitedHealthcare and Optum RX in the United
States) in order to receive treatment which is covered under the plan.
Medical treatment: Refers to any surgery or Medical treatment performed by a Doctor, considered to be Medically required, in order
to diagnose, cure or alleviate an Illness or injury.
Medically assisted reproduction: See under Fertility treatment.
Medically required/medical necessity/absolute necessity: Refers in respect of this plan to treatment, services, supplies and
equipment recommended by a qualified healthcare professional which are defined from a medical point of view as appropriate and
necessary.
To qualify, they must meet the following criteria:
be necessary in order to diagnose or treat an Illness and/or injury suffered by a patient;
be appropriate to the diagnosis, symptoms or treatment of the patient (in the sense of taking into account patient safety
and the cost of the treatment);
comply with medical and scientific standards and knowledge at the time of administration of the treatment;
not be provided primarily for the patient’s comfort and/or that of their Doctor;
be clinically justified in terms of scale, duration, and demonstrated and proven medical effect, frequency, level and type;
be dispensed in an appropriate healthcare facility and room and be of the appropriate quality to treat the patient’s medical
condition.
Member: Person, under the age of 71 on the date of enrollment regardless of their status, who is a member of ASFE and has
submitted an Application for coverage under the plan which has been accepted in writing as defined in section 5.2 / Life of your plan
p.32, in the chapter Your enrollment in the plan and persons insured, for themselves and any Dependents and who has agreed to
fulfill the corresponding obligations, including payment of the Premium specified at the time of enrollment in the plan.
Open group insurance plan: Refers to insurance plans in which enrollment is available on an individual and voluntary basis.
Individuals then form a group through a Contracting association and enroll in the insurance plan.
Orthodontics: Orthodontics is a dental specialty dedicated to the correction of improper positioning of the jaws and teeth in order
to optimize the closure of the mouth (occlusion), to ensure proper functioning and alignment.
Orthoptics: Paramedical specialty aiming to evaluate and measure ocular deviation and ensure rehabilitation of the eyes in case of
binocular vision disorders: strabismus, heterophoria (deviation of the visual axes) or convergence insufficiency.
Osteopathy: Manual therapeutic method using techniques of spinal or muscular manipulation of the musculoskeletal and myofascial
system in order to alleviate certain functional disorders.
Outpatient hospitalization: Treatment administered following admission to a Hospital or medical center on an outpatient basis,
including the use of a Hospital room and nursing care, but which does not require an overnight stay and where the patient is
discharged the same day.
Outpatient surgery: Surgery performed in a healthcare facility or medical office where the patient is admitted and discharged on
the same day.
Palliative care: With respect to a progressive and incurable Illness, this refers to a treatment which does not significantly improve
or cure the condition but aims to relieve the physical and psychological suffering related to the symptoms of the Illness and maintain
relative ‘quality of life’. Outpatient and inpatient care administered following a diagnosis which confirms the terminal and incurable
nature of the Illness is covered under this benefit, as is the reimbursement of physical care, the cost of a room in a Hospital or hospice,
nursing care and prescription drugs.
Paramedical practitioners: A qualified health professional working in a paramedical and who is officially registered, qualified and
recognized in the country in which the medical care is delivered and in which they practice and who has the additional experience
and qualifications required to deliver this care. Paramedical practitioners are physical therapists, nurses, chiropodists/podiatrists,
speech therapists and orthoptists.
Partner: Person under the age of 71 at the time of enrollment bound to the Member by a civil partnership agreement. A civil
partnership is a contract signed by two adult persons of the opposite or same sex in order to share their life together (Article 515-1
of the French Civil Code). See also Common-law spouse and Spouse.
Period of benefits / period of coverage: Continuous period of 365 days during which the Member and any Dependents are covered
by virtue of enrollment in the plan. It starts from the effective date of enrollment in the plan as specified on the Certificate of insurance
(other than in cases of early termination under the rules of the plan 355.2.9 Cessation of membership and end of coverage (right of
withdrawal and termination) p35)).
Periodontics: Dental treatment prescribed for disorders of the structures supporting the teeth (particularly the gums).
Physical therapy: All treatment dispensed by a licensed physical therapist for which a Doctor’s prescription is issued before the start
of treatment. Coverage is limited to the number of sessions and the specific reimbursement limit applicable to this type of treatment,
as specified in the Benefits schedule. If more sessions are required, a report justifying the need to extend the treatment must be
produced. Physical therapy excludes certain treatments including mud therapy, Pilates, relaxation massage, Rolfing, MILTA therapy
and all other methods which are not recognized by the scientific medical community.
Physiotherapy: Physiotherapy, for the purposes of the plan, is all treatment which can be dispensed by a licensed physical therapist.
This excludes, for the purposes of this plan, certain treatments such as mud therapy, Pilates, massage, Rolfing and MILTA therapy.
Plan from the 1st Euro/Dollar: A plan where medical expenses are reimbursed from the 1st euro/dollar spent (within the limits of the
selected benefits), i.e. without a contribution from a basic organization (such as a benefits scheme).
Policyholder: The Policyholder is ASFE who has arranged this group plan for the benefit of its insured Members.
Postnatal care: All post-partum medical care received by the mother in a period of up to six weeks after the birth.
Precertification: Precertification agreement formalized in writing and issued to the Insured member by the Insurer or the
Administrator before incurring certain types of medical expenses or accessing services such as hospitalization, medical treatments
Medical network: Means all Hospitals or associated care facilities and healthcare practitioners officially listed by your plan
Administrator (MSH International) or by the service partners selected by them (such as UnitedHealthcare and Optum RX in the United
States) in order to receive treatment which is covered under the plan.
Medical treatment: Refers to any surgery or Medical treatment performed by a Doctor, considered to be Medically required, in order
to diagnose, cure or alleviate an Illness or injury.
Medically assisted reproduction: See under Fertility treatment.
Medically required/medical necessity/absolute necessity: Refers in respect of this plan to treatment, services, supplies and
equipment recommended by a qualified healthcare professional which are defined from a medical point of view as appropriate and
necessary.
To qualify, they must meet the following criteria:
be necessary in order to diagnose or treat an Illness and/or injury suffered by a patient;
be appropriate to the diagnosis, symptoms or treatment of the patient (in the sense of taking into account patient safety
and the cost of the treatment);
comply with medical and scientific standards and knowledge at the time of administration of the treatment;
not be provided primarily for the patient’s comfort and/or that of their Doctor;
be clinically justified in terms of scale, duration, and demonstrated and proven medical effect, frequency, level and type;
be dispensed in an appropriate healthcare facility and room and be of the appropriate quality to treat the patient’s medical
condition.
Member: Person, under the age of 71 on the date of enrollment regardless of their status, who is a member of ASFE and has
submitted an Application for coverage under the plan which has been accepted in writing as defined in section 5.2 / Life of your plan
p.32, in the chapter Your enrollment in the plan and persons insured, for themselves and any Dependents and who has agreed to
fulfill the corresponding obligations, including payment of the Premium specified at the time of enrollment in the plan.
Open group insurance plan: Refers to insurance plans in which enrollment is available on an individual and voluntary basis.
Individuals then form a group through a Contracting association and enroll in the insurance plan.
Orthodontics: Orthodontics is a dental specialty dedicated to the correction of improper positioning of the jaws and teeth in order
to optimize the closure of the mouth (occlusion), to ensure proper functioning and alignment.
Orthoptics: Paramedical specialty aiming to evaluate and measure ocular deviation and ensure rehabilitation of the eyes in case of
binocular vision disorders: strabismus, heterophoria (deviation of the visual axes) or convergence insufficiency.
Osteopathy: Manual therapeutic method using techniques of spinal or muscular manipulation of the musculoskeletal and myofascial
system in order to alleviate certain functional disorders.
Outpatient hospitalization: Treatment administered following admission to a Hospital or medical center on an outpatient basis,
including the use of a Hospital room and nursing care, but which does not require an overnight stay and where the patient is
discharged the same day.
Outpatient surgery: Surgery performed in a healthcare facility or medical office where the patient is admitted and discharged on
the same day.
Palliative care: With respect to a progressive and incurable Illness, this refers to a treatment which does not significantly improve
or cure the condition but aims to relieve the physical and psychological suffering related to the symptoms of the Illness and maintain
relative ‘quality of life’. Outpatient and inpatient care administered following a diagnosis which confirms the terminal and incurable
nature of the Illness is covered under this benefit, as is the reimbursement of physical care, the cost of a room in a Hospital or hospice,
nursing care and prescription drugs.
Paramedical practitioners: A qualified health professional working in a paramedical and who is officially registered, qualified and
recognized in the country in which the medical care is delivered and in which they practice and who has the additional experience
and qualifications required to deliver this care. Paramedical practitioners are physical therapists, nurses, chiropodists/podiatrists,
speech therapists and orthoptists.
Partner: Person under the age of 71 at the time of enrollment bound to the Member by a civil partnership agreement. A civil
partnership is a contract signed by two adult persons of the opposite or same sex in order to share their life together (Article 515-1
of the French Civil Code). See also Common-law spouse and Spouse.
Period of benefits / period of coverage: Continuous period of 365 days during which the Member and any Dependents are covered
by virtue of enrollment in the plan. It starts from the effective date of enrollment in the plan as specified on the Certificate of insurance
(other than in cases of early termination under the rules of the plan 355.2.9 Cessation of membership and end of coverage (right of
withdrawal and termination) p35)).
Periodontics: Dental treatment prescribed for disorders of the structures supporting the teeth (particularly the gums).
Physical therapy: All treatment dispensed by a licensed physical therapist for which a Doctor’s prescription is issued before the start
of treatment. Coverage is limited to the number of sessions and the specific reimbursement limit applicable to this type of treatment,
as specified in the Benefits schedule. If more sessions are required, a report justifying the need to extend the treatment must be
produced. Physical therapy excludes certain treatments including mud therapy, Pilates, relaxation massage, Rolfing, MILTA therapy
and all other methods which are not recognized by the scientific medical community.
Physiotherapy: Physiotherapy, for the purposes of the plan, is all treatment which can be dispensed by a licensed physical therapist.
This excludes, for the purposes of this plan, certain treatments such as mud therapy, Pilates, massage, Rolfing and MILTA therapy.
Plan from the 1st Euro/Dollar: A plan where medical expenses are reimbursed from the 1st euro/dollar spent (within the limits of the
selected benefits), i.e. without a contribution from a basic organization (such as a benefits scheme).
Policyholder: The Policyholder is ASFE who has arranged this group plan for the benefit of its insured Members.
Postnatal care: All post-partum medical care received by the mother in a period of up to six weeks after the birth.
Precertification: Precertification agreement formalized in writing and issued to the Insured member by the Insurer or the
Administrator before incurring certain types of medical expenses or accessing services such as hospitalization, medical treatments
9
provided as a series of treatments, costly treatments, or prostheses of any kind (on presentation of an appropriate detailed and
circumstantial medical report and a fully costed estimate).
Pre-existing medical condition: Pre-existing conditions: any Illness, disorder or injury or associated symptoms which developed
before the date of enrollment in the plan, of which the Member or their Dependents were aware, or of which they could reasonably
have been aware.
Pregnancy: Period between the date of conception and the date of delivery.
Premium: Amount paid by the Member in return for benefits provided by the Insurer.
Premium notice: A Premium notice (sometimes also called a renewal notice) is a document which specifies the amount of your
insurance Premiums and the period covered. The payment of the insurance Premium is made on the date specified in the Premium
notice.
Prenatal care: Refers to all standard, customary screening and follow-up examinations during Pregnancy.
In respect of high-risk pregnancies, Prenatal care may include:
- amniocentesis and DNA tests if directly linked to amniocentesis covered under the insurance plan;
- tests for Spina Bifida;
- triple (Bart’s) or quadruple tests.
Prescription drugs: Refers to all products (including hypodermic needles, insulin and syringes), the delivery of which requires a
prescription issued by a Doctor to treat an Illness whose diagnosis has been confirmed or with the aim of compensating for a
deficiency in a substance which is essential to the body. These Prescription drugs must have a proven medical effect on the Illness
being treated and be approved by the regulatory authorities and pharmaceutical supervisory bodies of the country in which they
were prescribed.
Primary care/routine healthcare: All healthcare Services provided by healthcare professionals excluding hospitalization or stays in
healthcare or socio-medical facilities. It includes, for example, consultations in a private medical practice or health center, laboratory
tests, x-rays taken in the doctor’s office etc. Consultations carried out in Hospitals but not involving hospitalization (also known as
‘outpatient’ consultations) are generally classed as Primary care.
Private room: Service offered by healthcare facilities, allowing an inpatient to be accommodated in a single room. Deluxe and VIP
rooms and suites are not covered.
Psychiatric treatment and care: Management and care of a person who is suffering from a severe mental health problem, requiring
hospitalization in a specialized unit.
Psychiatry: Psychiatry is the medical treatment of mental Illness, whatever the cause: psychological, neurological or psychosocial.
The psychiatrist is not a psychoanalyst, psychologist or psychotherapist (unless they have had additional training), but their medical
degree enables them to prescribe medication or decide on psychiatric hospitalization. Consultations with and prescriptions from a
Psychiatrist are covered under this plan (subject to a Waiting period of 12 months).
Refractive surgery: Surgical treatments, usually performed using laser, for visual corrections of myopia, hyperopia, astigmatism and
keratoconus.
Rehabilitation immediately following hospitalization: Rehabilitation directly following hospitalization, commenced within a
maximum of 30 days of the end of the stay in hospital, dispensed as a combination of therapies, which may include occupational
therapy, physical therapy and Speech therapy in order to restore function and/or normal shape after an injury or serious Illness.
Request for prior approval: Before incurring certain medical expenses or commencing some types of treatment or Services such as
hospitalization, medical treatments provided as a series of treatments, costly treatments or Prostheses of any kind, the Insured
member must first request and obtain the agreement of the Insurer or the Administrator to obtain a Precertification agreement (on
presentation of a detailed and circumstantial medical report as appropriate and a fully costed estimate).
Routine dental care: All Routine dental care including an annual dental check-up, root canal work, scaling, sealing of fissures,
treatment of tooth decay (amalgam), application of fluoride and dental x-rays, excluding tooth whitening treatments.
Routine healthcare: Treatments, excluding Routine dental care, performed by a General practitioner or Specialist who is a qualified
doctor of medicine and is licensed to practice medicine under the laws of the country where the treatment is administered in their
medical or surgical office and which do not require the patient to be admitted to Hospital.
Selected coverage zone: Refers to the Coverage zone selected by the Member for themselves and their Dependents, and for which
the appropriate Premium has been fixed by the Insurer based on Usual, customary and reasonable healthcare costs charged in this
group of countries. Subject to payment of the appropriate Premium, the Member may opt for a Selected coverage zone for
themselves and their Dependents which is higher than that corresponding to their Main country of residence. They cannot, however,
opt for a Selected coverage zone lower than that corresponding to their Main country of residence.
The plan offers 5 coverage zones (see section entitled ‘Specific country of residence and Coverage zones under the plan’).
Semi-private room: Service offered by healthcare facilities, allowing an inpatient to be accommodated in a double room. Deluxe
and VIP rooms and suites are not covered.
Service: All Services specified in the Benefits schedule of the plan.
Specialist: Refers to a qualified Doctor who is officially licensed, trained and approved in the country where the treatment is
administered and where they practice and who has the additional experience and qualifications required to practice a recognized
medical specialty: techniques for diagnosis, treatment and prevention specific to a particular field of medicine.
Speech therapy: Speech therapy is a paramedical discipline which treats persons presenting with disorders related to
communication and the spoken or written language by means of speech rehabilitation.
Spouse: Spouse who is not legally separated or divorced, whether or not they are in paid employment, and under the age of 71 on
the date of enrollment. To facilitate the reading of this information booklet serving as the general terms and conditions, the term
‘Spouse’ will refer generically to the Spouse, partner or Common-law spouse of the Member.
Subrogation: Refers to the rights which the Administrator (MSH International) can exercise on behalf of the Insurer to recover any
expenses or costs from another insurance company, national health insurance scheme or any source linked to the reimbursement
of treatment insured under this plan.
provided as a series of treatments, costly treatments, or prostheses of any kind (on presentation of an appropriate detailed and
circumstantial medical report and a fully costed estimate).
Pre-existing medical condition: Pre-existing conditions: any Illness, disorder or injury or associated symptoms which developed
before the date of enrollment in the plan, of which the Member or their Dependents were aware, or of which they could reasonably
have been aware.
Pregnancy: Period between the date of conception and the date of delivery.
Premium: Amount paid by the Member in return for benefits provided by the Insurer.
Premium notice: A Premium notice (sometimes also called a renewal notice) is a document which specifies the amount of your
insurance Premiums and the period covered. The payment of the insurance Premium is made on the date specified in the Premium
notice.
Prenatal care: Refers to all standard, customary screening and follow-up examinations during Pregnancy.
In respect of high-risk pregnancies, Prenatal care may include:
- amniocentesis and DNA tests if directly linked to amniocentesis covered under the insurance plan;
- tests for Spina Bifida;
- triple (Bart’s) or quadruple tests.
Prescription drugs: Refers to all products (including hypodermic needles, insulin and syringes), the delivery of which requires a
prescription issued by a Doctor to treat an Illness whose diagnosis has been confirmed or with the aim of compensating for a
deficiency in a substance which is essential to the body. These Prescription drugs must have a proven medical effect on the Illness
being treated and be approved by the regulatory authorities and pharmaceutical supervisory bodies of the country in which they
were prescribed.
Primary care/routine healthcare: All healthcare Services provided by healthcare professionals excluding hospitalization or stays in
healthcare or socio-medical facilities. It includes, for example, consultations in a private medical practice or health center, laboratory
tests, x-rays taken in the doctor’s office etc. Consultations carried out in Hospitals but not involving hospitalization (also known as
‘outpatient’ consultations) are generally classed as Primary care.
Private room: Service offered by healthcare facilities, allowing an inpatient to be accommodated in a single room. Deluxe and VIP
rooms and suites are not covered.
Psychiatric treatment and care: Management and care of a person who is suffering from a severe mental health problem, requiring
hospitalization in a specialized unit.
Psychiatry: Psychiatry is the medical treatment of mental Illness, whatever the cause: psychological, neurological or psychosocial.
The psychiatrist is not a psychoanalyst, psychologist or psychotherapist (unless they have had additional training), but their medical
degree enables them to prescribe medication or decide on psychiatric hospitalization. Consultations with and prescriptions from a
Psychiatrist are covered under this plan (subject to a Waiting period of 12 months).
Refractive surgery: Surgical treatments, usually performed using laser, for visual corrections of myopia, hyperopia, astigmatism and
keratoconus.
Rehabilitation immediately following hospitalization: Rehabilitation directly following hospitalization, commenced within a
maximum of 30 days of the end of the stay in hospital, dispensed as a combination of therapies, which may include occupational
therapy, physical therapy and Speech therapy in order to restore function and/or normal shape after an injury or serious Illness.
Request for prior approval: Before incurring certain medical expenses or commencing some types of treatment or Services such as
hospitalization, medical treatments provided as a series of treatments, costly treatments or Prostheses of any kind, the Insured
member must first request and obtain the agreement of the Insurer or the Administrator to obtain a Precertification agreement (on
presentation of a detailed and circumstantial medical report as appropriate and a fully costed estimate).
Routine dental care: All Routine dental care including an annual dental check-up, root canal work, scaling, sealing of fissures,
treatment of tooth decay (amalgam), application of fluoride and dental x-rays, excluding tooth whitening treatments.
Routine healthcare: Treatments, excluding Routine dental care, performed by a General practitioner or Specialist who is a qualified
doctor of medicine and is licensed to practice medicine under the laws of the country where the treatment is administered in their
medical or surgical office and which do not require the patient to be admitted to Hospital.
Selected coverage zone: Refers to the Coverage zone selected by the Member for themselves and their Dependents, and for which
the appropriate Premium has been fixed by the Insurer based on Usual, customary and reasonable healthcare costs charged in this
group of countries. Subject to payment of the appropriate Premium, the Member may opt for a Selected coverage zone for
themselves and their Dependents which is higher than that corresponding to their Main country of residence. They cannot, however,
opt for a Selected coverage zone lower than that corresponding to their Main country of residence.
The plan offers 5 coverage zones (see section entitled ‘Specific country of residence and Coverage zones under the plan’).
Semi-private room: Service offered by healthcare facilities, allowing an inpatient to be accommodated in a double room. Deluxe
and VIP rooms and suites are not covered.
Service: All Services specified in the Benefits schedule of the plan.
Specialist: Refers to a qualified Doctor who is officially licensed, trained and approved in the country where the treatment is
administered and where they practice and who has the additional experience and qualifications required to practice a recognized
medical specialty: techniques for diagnosis, treatment and prevention specific to a particular field of medicine.
Speech therapy: Speech therapy is a paramedical discipline which treats persons presenting with disorders related to
communication and the spoken or written language by means of speech rehabilitation.
Spouse: Spouse who is not legally separated or divorced, whether or not they are in paid employment, and under the age of 71 on
the date of enrollment. To facilitate the reading of this information booklet serving as the general terms and conditions, the term
‘Spouse’ will refer generically to the Spouse, partner or Common-law spouse of the Member.
Subrogation: Refers to the rights which the Administrator (MSH International) can exercise on behalf of the Insurer to recover any
expenses or costs from another insurance company, national health insurance scheme or any source linked to the reimbursement
of treatment insured under this plan.
10
Termination: Termination is the formal process by which the Insurer, the Contracting association or the Member puts an end to the
plan or enrollment in the plan which binds them, see chapter 5.2.9 Cessation of membership and end of coverage (right of withdrawal
and termination) p.35.
Traditional Chinese medicine: Asian therapeutic method which does not strictly differentiate between the mind and body and is
based on a holistic approach to the person. The treatment is based on five main pillars: Acupuncture, diet, drug therapy with
vegetable, mineral and animal substances, massage and movement.
Treatment of cancer (Oncology): Refers to fees payable to specialists, examinations, radiotherapy costs, chemotherapy and hospital
charges incurred in connection with the treatment of a malignant tumor, tissue or cells, characterized by the uncontrolled growth
and spread of malignant cells invading the tissues.
Unforeseen illness: Any deterioration in the state of health certified by a competent medical authority which is sudden, unexpected
and requires the intervention of a Doctor in less than 48 hours.
Usual, customary and reasonable costs: Usual, customary and reasonable costs which will be reimbursed under the plan are
defined as reasonable medical expenses commonly charged in the relevant country for the specific treatment received, in accordance
with standard and generally accepted medical procedures. Medical expenses deemed to be excessive, unreasonable or unusual
considering the country in which they were incurred, will not be covered or the amount of benefits paid will be limited. The
abbreviation UCR will be used in this information booklet serving as the general terms and conditions for ease of reference.
Vaccinations: Refers to all vaccines and boosters required by the health authorities of the country in which the Vaccination is
administered and any medically required Vaccinations for travel to a foreign country as well as malaria prevention treatment. The
cost of the consultation and the purchase of the vaccine are included.
Waiting period: Period specified in the plan and shown in the Benefits schedule, during which membership is active but the benefits
are not yet accessible.
The Waiting periods apply from the Effective date of enrollment of each person insured under the plan.
Termination: Termination is the formal process by which the Insurer, the Contracting association or the Member puts an end to the
plan or enrollment in the plan which binds them, see chapter 5.2.9 Cessation of membership and end of coverage (right of withdrawal
and termination) p.35.
Traditional Chinese medicine: Asian therapeutic method which does not strictly differentiate between the mind and body and is
based on a holistic approach to the person. The treatment is based on five main pillars: Acupuncture, diet, drug therapy with
vegetable, mineral and animal substances, massage and movement.
Treatment of cancer (Oncology): Refers to fees payable to specialists, examinations, radiotherapy costs, chemotherapy and hospital
charges incurred in connection with the treatment of a malignant tumor, tissue or cells, characterized by the uncontrolled growth
and spread of malignant cells invading the tissues.
Unforeseen illness: Any deterioration in the state of health certified by a competent medical authority which is sudden, unexpected
and requires the intervention of a Doctor in less than 48 hours.
Usual, customary and reasonable costs: Usual, customary and reasonable costs which will be reimbursed under the plan are
defined as reasonable medical expenses commonly charged in the relevant country for the specific treatment received, in accordance
with standard and generally accepted medical procedures. Medical expenses deemed to be excessive, unreasonable or unusual
considering the country in which they were incurred, will not be covered or the amount of benefits paid will be limited. The
abbreviation UCR will be used in this information booklet serving as the general terms and conditions for ease of reference.
Vaccinations: Refers to all vaccines and boosters required by the health authorities of the country in which the Vaccination is
administered and any medically required Vaccinations for travel to a foreign country as well as malaria prevention treatment. The
cost of the consultation and the purchase of the vaccine are included.
Waiting period: Period specified in the plan and shown in the Benefits schedule, during which membership is active but the benefits
are not yet accessible.
The Waiting periods apply from the Effective date of enrollment of each person insured under the plan.