Seguro Internacional | Full
International Evolution Standard 5000
Deductible: 5.000 USD and Max. Coverage: 500.000 USD/Year
From
US$ 67 . 62
Evolution Health Plan| StandardPage 1 of 9HDI/UK/EVO/TOB-STAN/04/21
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1 Hospital Benefits
IN-PATIENT HOSPITAL STAY – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
All required medical treatment provided to you when you are admitted as a registered in-patient in
a hospital for a period of not less than 24 hours, and only when appropriate diagnostic procedures
and/or treatment is not available on an out-patient or day-patient basis.
To include:
• Cost of hospital accommodation in a standard single bedded room (where available), nursing,
operating theatre fees, high dependency/intensive care/coronary care unit and special nursing
fees.
• Surgeons’, anaesthetists, consultants and physician fees.
• Physiotherapy.
• Internal prosthesis, medical aids/devices where used as an integral part of a surgical
procedure.
• Prescribed drugs and dressings.
• Diagnostic tests including x-rays, pathology and MRI/CT/PET scans.
DAY-PATIENT TREATMENT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Any surgical or medical procedures that you receive which are on an out-patient basis, but where
you require a period of recovery in a hospital bed. It includes the costs of hospital accommodation,
operating theatre, nursing, surgeons, anaesthetists, consultants and physician fees, diagnostic
procedures and prescribed drugs and medicines.
PARENTAL HOSPITAL STAY
Hospital accommodation costs for one insured person to stay with an insured child dependant,
who is under age 19, and being admitted to hospital as an in-patient for medical treatment covered
by this policy.
IN-PATIENT PSYCHIATRIC TREATMENT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Medical treatment provided when you are admitted as a registered in-patient in a recognised
psychiatric unit of a hospital. It includes the cost of hospital accommodation in a standard single
bedded room (where available), consultant psychiatrist’s/psychologist’s fees, diagnostic procedures
and prescribed drugs and medicines.
ACCIDENT AND EMERGENCY ROOM TREATMENT
Treatment given in a hospital casualty ward or emergency room immediately following an accident
or the sudden onset of a serious medical condition. Resulting in eligible in-patient or day-patient
treatment. By immediate we mean within 2 hours of the eligible incident causing the problem.
Overall maximum limit
This is the maximum amount of money we will pay to, or on behalf of, each insured person in each
period of insurance. Benefit provisions where the limit is ‘Full Refund’ are collectively subject to the
overall maximum limit applying. For the avoidance of doubt, if a benefit is not included below then it is
not covered by your policy unless agreed by us as an exception.
Evolution Health Plan
Standard
$ / £ / €
500,000
Full Refund
Full Refund
Full Refund
Not Covered
Full Refund
A
B
C
D
E
1 Hospital Benefits
IN-PATIENT HOSPITAL STAY – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
All required medical treatment provided to you when you are admitted as a registered in-patient in
a hospital for a period of not less than 24 hours, and only when appropriate diagnostic procedures
and/or treatment is not available on an out-patient or day-patient basis.
To include:
• Cost of hospital accommodation in a standard single bedded room (where available), nursing,
operating theatre fees, high dependency/intensive care/coronary care unit and special nursing
fees.
• Surgeons’, anaesthetists, consultants and physician fees.
• Physiotherapy.
• Internal prosthesis, medical aids/devices where used as an integral part of a surgical
procedure.
• Prescribed drugs and dressings.
• Diagnostic tests including x-rays, pathology and MRI/CT/PET scans.
DAY-PATIENT TREATMENT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Any surgical or medical procedures that you receive which are on an out-patient basis, but where
you require a period of recovery in a hospital bed. It includes the costs of hospital accommodation,
operating theatre, nursing, surgeons, anaesthetists, consultants and physician fees, diagnostic
procedures and prescribed drugs and medicines.
PARENTAL HOSPITAL STAY
Hospital accommodation costs for one insured person to stay with an insured child dependant,
who is under age 19, and being admitted to hospital as an in-patient for medical treatment covered
by this policy.
IN-PATIENT PSYCHIATRIC TREATMENT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Medical treatment provided when you are admitted as a registered in-patient in a recognised
psychiatric unit of a hospital. It includes the cost of hospital accommodation in a standard single
bedded room (where available), consultant psychiatrist’s/psychologist’s fees, diagnostic procedures
and prescribed drugs and medicines.
ACCIDENT AND EMERGENCY ROOM TREATMENT
Treatment given in a hospital casualty ward or emergency room immediately following an accident
or the sudden onset of a serious medical condition. Resulting in eligible in-patient or day-patient
treatment. By immediate we mean within 2 hours of the eligible incident causing the problem.
Overall maximum limit
This is the maximum amount of money we will pay to, or on behalf of, each insured person in each
period of insurance. Benefit provisions where the limit is ‘Full Refund’ are collectively subject to the
overall maximum limit applying. For the avoidance of doubt, if a benefit is not included below then it is
not covered by your policy unless agreed by us as an exception.
Evolution Health Plan
Standard
$ / £ / €
500,000
Full Refund
Full Refund
Full Refund
Not Covered
Full Refund
Evolution Health Plan| StandardPage 2 of 9HDI/UK/EVO/TOB-STAN/04/21
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REHABILITATION CARE – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Treatment received on an in-patient basis in a recognised rehabilitation unit, under the supervision
and direction of a physician, to restore health and mobility after an accident, injury or illness
covered by this policy.
KIDNEY DIALYSIS BENEFIT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Kidney dialysis needed temporarily for sudden kidney failure resulting from a disease or injury,
covered by your policy.
ORGAN IMPLANTATION BENEFIT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Costs directly related to the implantation of the following natural human organs; kidney, liver,
heart, lung, stem cell, bone marrow and skin grafts (where medically necessary and not for
cosmetic purposes).
• There is NO cover for the costs associated with locating a replacement organ, or for the
removal of the organ from the donor, or any transportation and administration costs.
• There is NO cover for costs associated with procurement and/or implantation of an artificial
and /or non-human organ.
• There is NO costs for medical treatment associated with cryopreservation, implantation or
reimplantation of living cells or living tissues whether autologous or provided by a donor.
DAY-PATIENT PSYCHIATRIC COVER
The cost of hospital accommodation in a standard single bedded room (where available) in a
registered psychiatric unit for a psychiatric illness including, consultant psychiatric fees, diagnostic
procedures and prescribed drugs and medicines.
LOCAL AMBULANCE SERVICES
The cost of provision of ambulance services to transport you to hospital in the event of a medical
emergency.
IN-PATIENT CHRONIC CONDITION BENEFITS
In-patient treatment of chronic medical conditions diagnosed after the start date of the policy or
agreed to be covered in writing at application stage.
Chronic or end stage renal failure which requires regular or long term dialysis is not covered under this
benefit.
2 Cancer Care Benefit
A CANCER TREATMENT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
From the date an insured person is diagnosed with cancer, subject to it not pre-existing the start
date of the policy, whether it is in its acute, chronic or terminal stage, all and any treatment received
thereafter on an in-patient, day-patient or out-patient basis involving: consultations, diagnostic
tests, scans, investigations, prescribed drugs and dressings, chemotherapy, radiotherapy, stem cell
transplants (from either bone marrow or blood), routine management and palliative treatments;
will be assessed and paid for under this benefit.
Eligible costs incurred up until the point of diagnosis are not assessed under this benefit but may be
covered under any out-patient benefit if included in your plan.
F EXTERNAL PROSTHESES
An external device (i.e. artificial limbs) that substitutes or supplements a missing part of the body.
2,500
Full Refund –
maximum 13
weeks
Not Covered
Full Refund
Full Refund
Not Covered
Not Covered
Full Refund
G
H
K
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REHABILITATION CARE – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Treatment received on an in-patient basis in a recognised rehabilitation unit, under the supervision
and direction of a physician, to restore health and mobility after an accident, injury or illness
covered by this policy.
KIDNEY DIALYSIS BENEFIT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Kidney dialysis needed temporarily for sudden kidney failure resulting from a disease or injury,
covered by your policy.
ORGAN IMPLANTATION BENEFIT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Costs directly related to the implantation of the following natural human organs; kidney, liver,
heart, lung, stem cell, bone marrow and skin grafts (where medically necessary and not for
cosmetic purposes).
• There is NO cover for the costs associated with locating a replacement organ, or for the
removal of the organ from the donor, or any transportation and administration costs.
• There is NO cover for costs associated with procurement and/or implantation of an artificial
and /or non-human organ.
• There is NO costs for medical treatment associated with cryopreservation, implantation or
reimplantation of living cells or living tissues whether autologous or provided by a donor.
DAY-PATIENT PSYCHIATRIC COVER
The cost of hospital accommodation in a standard single bedded room (where available) in a
registered psychiatric unit for a psychiatric illness including, consultant psychiatric fees, diagnostic
procedures and prescribed drugs and medicines.
LOCAL AMBULANCE SERVICES
The cost of provision of ambulance services to transport you to hospital in the event of a medical
emergency.
IN-PATIENT CHRONIC CONDITION BENEFITS
In-patient treatment of chronic medical conditions diagnosed after the start date of the policy or
agreed to be covered in writing at application stage.
Chronic or end stage renal failure which requires regular or long term dialysis is not covered under this
benefit.
2 Cancer Care Benefit
A CANCER TREATMENT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
From the date an insured person is diagnosed with cancer, subject to it not pre-existing the start
date of the policy, whether it is in its acute, chronic or terminal stage, all and any treatment received
thereafter on an in-patient, day-patient or out-patient basis involving: consultations, diagnostic
tests, scans, investigations, prescribed drugs and dressings, chemotherapy, radiotherapy, stem cell
transplants (from either bone marrow or blood), routine management and palliative treatments;
will be assessed and paid for under this benefit.
Eligible costs incurred up until the point of diagnosis are not assessed under this benefit but may be
covered under any out-patient benefit if included in your plan.
F EXTERNAL PROSTHESES
An external device (i.e. artificial limbs) that substitutes or supplements a missing part of the body.
2,500
Full Refund –
maximum 13
weeks
Not Covered
Full Refund
Full Refund
Not Covered
Not Covered
Full Refund
Evolution Health Plan| StandardPage 3 of 9HDI/UK/EVO/TOB-STAN/04/21
C
D
E
F
G
H
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
2,5003 Out-Patient Benefits
A Full Refund
B 1,000 for treatment
received pre or post
op or within 6 weeks
following an eligible
in-patient stay
OUT-PATIENT MINOR SURGERY
Minor surgical procedures carried out in a doctors clinic/consulting rooms or out-patient centre by
a registered medical practitioner.
OUT-PATIENT SERVICES
The services ordered by a physician who is licensed as a general practitioner, consultant or
physician, including prescribed drugs, medicines and dressings
DIAGNOSTIC TESTS, X-RAYS, PATHOLOGY
The cost of diagnostic tests, investigations including ECG, X-rays, pathology and histology.
MRI/CT/PET SCANS
The cost of MRI/CT/PET scans when ordered by a physician.
PHYSIOTHERAPY
Treatment provided by a licensed Physiotherapist.
MEDICAL AIDS AND DEVICES
The cost of hiring mobility aids and devices including: walking sticks or frames, wheelchairs and
crutches.
COMPLEMENTARY THERAPIES
Chiropractic, homeopathy, osteopathy, acupuncture, ayurvedic, herbal and Chinese medicines,
consultations with registered practitioners, including prescribed drugs and medicines.
HORMONE REPLACEMENT THERAPY
Treatment received to relieve the symptoms of the menopause, including; prescribed medicines,
patches and implants.
I Not Covered
J
K
Not Covered
Not Covered
OUT-PATIENT PSYCHIATRIC TREATMENT – PRE-AUTHORISATION IS REQUIRED FOR THIS
BENEFIT, A 12 MONTH WAIT PERIOD APPLIES TO THIS BENEFIT – MUST BE REFERRED BY A
PHYSICIAN
Treatment of any psychiatric and psychological disorders by a consultant psychiatrist/
psychotherapist, diagnosed after the start date of the policy, including consultations and prescribed
drugs and medicines. This is subject to a referral from a primary physician.
HOME NURSING
Nursing at home where prescribed as medically necessary immediately following a period of in-
patient treatment covered by this policy. All nursing must be provided by a qualified nurse and
must be under the supervision and direction of a physician.
OUT-PATIENT CHRONIC CONDITION BENEFITS
Treatment of chronic medical conditions on an out-patient basis diagnosed after the start date of
the policy or agreed to be covered in writing at application stage.
Chronic or end stage renal failure which requires regular or long term dialysis is not covered under this
benefit.
C
D
E
F
G
H
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
2,5003 Out-Patient Benefits
A Full Refund
B 1,000 for treatment
received pre or post
op or within 6 weeks
following an eligible
in-patient stay
OUT-PATIENT MINOR SURGERY
Minor surgical procedures carried out in a doctors clinic/consulting rooms or out-patient centre by
a registered medical practitioner.
OUT-PATIENT SERVICES
The services ordered by a physician who is licensed as a general practitioner, consultant or
physician, including prescribed drugs, medicines and dressings
DIAGNOSTIC TESTS, X-RAYS, PATHOLOGY
The cost of diagnostic tests, investigations including ECG, X-rays, pathology and histology.
MRI/CT/PET SCANS
The cost of MRI/CT/PET scans when ordered by a physician.
PHYSIOTHERAPY
Treatment provided by a licensed Physiotherapist.
MEDICAL AIDS AND DEVICES
The cost of hiring mobility aids and devices including: walking sticks or frames, wheelchairs and
crutches.
COMPLEMENTARY THERAPIES
Chiropractic, homeopathy, osteopathy, acupuncture, ayurvedic, herbal and Chinese medicines,
consultations with registered practitioners, including prescribed drugs and medicines.
HORMONE REPLACEMENT THERAPY
Treatment received to relieve the symptoms of the menopause, including; prescribed medicines,
patches and implants.
I Not Covered
J
K
Not Covered
Not Covered
OUT-PATIENT PSYCHIATRIC TREATMENT – PRE-AUTHORISATION IS REQUIRED FOR THIS
BENEFIT, A 12 MONTH WAIT PERIOD APPLIES TO THIS BENEFIT – MUST BE REFERRED BY A
PHYSICIAN
Treatment of any psychiatric and psychological disorders by a consultant psychiatrist/
psychotherapist, diagnosed after the start date of the policy, including consultations and prescribed
drugs and medicines. This is subject to a referral from a primary physician.
HOME NURSING
Nursing at home where prescribed as medically necessary immediately following a period of in-
patient treatment covered by this policy. All nursing must be provided by a qualified nurse and
must be under the supervision and direction of a physician.
OUT-PATIENT CHRONIC CONDITION BENEFITS
Treatment of chronic medical conditions on an out-patient basis diagnosed after the start date of
the policy or agreed to be covered in writing at application stage.
Chronic or end stage renal failure which requires regular or long term dialysis is not covered under this
benefit.
Evolution Health Plan| StandardPage 4 of 9HDI/UK/EVO/TOB-STAN/04/21
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B
C
4
5
Chronic Condition Benefits
Wellness Benefits ALL BENEFITS ARE SUBJECT TO A 12 MONTH WAIT PERIOD
A
A
HOSPICE CARE TREATMENT - PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Accommodation in a hospice for palliative treatment for an insured person who has been given a
terminal prognosis.
HIV AND AIDS TREATMENT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT, A TWO
YEAR WAIT PERIOD APPLIES TO THIS BENEFIT
Medical treatment for HIV and AIDS including related diseases where contracted as a direct result
of a blood transfusion received after the insured persons start date.
WELLNESS SCREENING
Including cancer screening (cervical smears, mammograms and prostate/colon/testicular), testing
for body temperature, pulse, blood pressure, respiration, full blood count, fasting blood sugar, lipid
(fats) profile, kidney function panel, liver function panel and thyroid panel.
This is not applicable to insured persons under the age of 16.
TRAVEL VACCINATIONS/PREVENTATIVE MEDICATIONS
Vaccinations and immunisations and preventative medications that are directly related to overseas
travel requirements.
CHILD VACCINATIONS
Routine and preventative vaccinations for an insured child up to age 10.
D
F
G
H
E
OPTICAL BENEFIT
One annual vision/eye test.
VISION BENEFIT
Contribution towards the cost of glasses or contact lenses where prescribed by an ophthalmologist
or optician.
This does not cover: contact lenses supplied for cosmetic purposes only, sunglasses of any kind,
replacement glasses or contact lenses where they were worn prior to the start date of an insured persons
policy.
LASER EYE BENEFIT
Treatment and consultations related to corrective laser eye treatment when performed by a
qualified ophthalmic surgeon.
This does not cover: laser eye surgery where glasses or contact lenses were worn prior to the start date of
an insured persons policy.
HEARING TEST BENEFIT
One annual hearing test.
HEARING AID BENEFIT
Contribution towards the costs of a hearing aid where prescribed by an audiologist/ENT Consultant.
Not Covered
Not Covered
Not Covered
Full Refund -
maximum 14
nights
50
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
B
B
C
4
5
Chronic Condition Benefits
Wellness Benefits ALL BENEFITS ARE SUBJECT TO A 12 MONTH WAIT PERIOD
A
A
HOSPICE CARE TREATMENT - PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT
Accommodation in a hospice for palliative treatment for an insured person who has been given a
terminal prognosis.
HIV AND AIDS TREATMENT – PRE-AUTHORISATION IS REQUIRED FOR THIS BENEFIT, A TWO
YEAR WAIT PERIOD APPLIES TO THIS BENEFIT
Medical treatment for HIV and AIDS including related diseases where contracted as a direct result
of a blood transfusion received after the insured persons start date.
WELLNESS SCREENING
Including cancer screening (cervical smears, mammograms and prostate/colon/testicular), testing
for body temperature, pulse, blood pressure, respiration, full blood count, fasting blood sugar, lipid
(fats) profile, kidney function panel, liver function panel and thyroid panel.
This is not applicable to insured persons under the age of 16.
TRAVEL VACCINATIONS/PREVENTATIVE MEDICATIONS
Vaccinations and immunisations and preventative medications that are directly related to overseas
travel requirements.
CHILD VACCINATIONS
Routine and preventative vaccinations for an insured child up to age 10.
D
F
G
H
E
OPTICAL BENEFIT
One annual vision/eye test.
VISION BENEFIT
Contribution towards the cost of glasses or contact lenses where prescribed by an ophthalmologist
or optician.
This does not cover: contact lenses supplied for cosmetic purposes only, sunglasses of any kind,
replacement glasses or contact lenses where they were worn prior to the start date of an insured persons
policy.
LASER EYE BENEFIT
Treatment and consultations related to corrective laser eye treatment when performed by a
qualified ophthalmic surgeon.
This does not cover: laser eye surgery where glasses or contact lenses were worn prior to the start date of
an insured persons policy.
HEARING TEST BENEFIT
One annual hearing test.
HEARING AID BENEFIT
Contribution towards the costs of a hearing aid where prescribed by an audiologist/ENT Consultant.
Not Covered
Not Covered
Not Covered
Full Refund -
maximum 14
nights
50
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Evolution Health Plan| StandardPage 5 of 9HDI/UK/EVO/TOB-STAN/04/21
6 Dental Treatment Benefits
A EMERGENCY DENTAL TREATMENT
Dental treatment for immediate pain relief where required as a direct result of an accident. Only
treatment received during the first 48 hours following the date of the accident is covered.
Please not there is no cover available for:
• Treatment where the injury was caused by eating or drinking anything, even if it contained a
foreign body.
• Treatment where the damage was caused by normal wear and tear.
• Treatment where the damage was caused by teeth brushing or any other oral hygiene
procedure.
• Treatment where the injury was caused by any means other than extra-oral impact.
• Emergency dental treatment shall not include; restorative or remedial work; the use of any
precious metals; orthodontic treatment of any kind; or dental surgery performed in a hospital,
unless dental surgery is the only treatment available to alleviate the pain.
B
C
D
E
NON-EMERGENCY ROUTINE DENTAL TREATMENT – A 6 MONTH WAIT PERIOD AND A 10%
CO-INSURANCE APPLIES TO THIS BENEFIT
Including: Routine examinations, cleaning and polishing, fillings using amalgams or composite
materials, extractions (not wisdom tooth), x-rays, moulds and treatment for the relief of an infection
including antibiotics and temporary fillings.
Please note there is no cover available for:
• The cost of precious metals in any dental procedure;
• Gingivitis, periodontosis, or gum disease of any kind.
• Dental procedures other than those stated above.
• Replacement of existing crowns, inlays, fillings, bridges or missing teeth apparent at the start
date of the policy.
NON-EMERGENCY MAJOR DENTAL TREATMENT – A 6 MONTH WAIT PERIOD AND A 10%
CO-INSURANCE APPLIES TO THIS BENEFIT
Root canal treatment, new porcelain crown, new inlay, new bridgework, repairs to crown or inlay,
repairs to bridge.
Please note there is no cover available for:
• The cost of precious metals in any dental procedure;
• Gingivitis, periodontitis, or gum disease of any kind.
• Dental procedures other than those stated above.
• Replacement of existing crowns, inlays, fillings, bridges or missing teeth apparent at the start
date of the policy.
EXTRACTION OF WISDOM TEETH - A 6 MONTH WAIT PERIOD AND A 10% CO-INSURANCE
APPLIES TO THIS BENEFIT - PRE-AUTHORISATION REQUIRED FOR IN-PATIENT TREATMENT.
Extraction of buried, impacted or un-erupted wisdom teeth on an in-patient, day-patient or out-
patient basis.
ORTHODONTIC TREATMENT - A 6 MONTH WAIT PERIOD AND A 10% CO-INSURANCE APPLIES
TO THIS BENEFIT
Orthodontic dental treatment for insured children under age 19.
Full Refund
Not Covered
Not Covered
Not Covered
Not Covered
6 Dental Treatment Benefits
A EMERGENCY DENTAL TREATMENT
Dental treatment for immediate pain relief where required as a direct result of an accident. Only
treatment received during the first 48 hours following the date of the accident is covered.
Please not there is no cover available for:
• Treatment where the injury was caused by eating or drinking anything, even if it contained a
foreign body.
• Treatment where the damage was caused by normal wear and tear.
• Treatment where the damage was caused by teeth brushing or any other oral hygiene
procedure.
• Treatment where the injury was caused by any means other than extra-oral impact.
• Emergency dental treatment shall not include; restorative or remedial work; the use of any
precious metals; orthodontic treatment of any kind; or dental surgery performed in a hospital,
unless dental surgery is the only treatment available to alleviate the pain.
B
C
D
E
NON-EMERGENCY ROUTINE DENTAL TREATMENT – A 6 MONTH WAIT PERIOD AND A 10%
CO-INSURANCE APPLIES TO THIS BENEFIT
Including: Routine examinations, cleaning and polishing, fillings using amalgams or composite
materials, extractions (not wisdom tooth), x-rays, moulds and treatment for the relief of an infection
including antibiotics and temporary fillings.
Please note there is no cover available for:
• The cost of precious metals in any dental procedure;
• Gingivitis, periodontosis, or gum disease of any kind.
• Dental procedures other than those stated above.
• Replacement of existing crowns, inlays, fillings, bridges or missing teeth apparent at the start
date of the policy.
NON-EMERGENCY MAJOR DENTAL TREATMENT – A 6 MONTH WAIT PERIOD AND A 10%
CO-INSURANCE APPLIES TO THIS BENEFIT
Root canal treatment, new porcelain crown, new inlay, new bridgework, repairs to crown or inlay,
repairs to bridge.
Please note there is no cover available for:
• The cost of precious metals in any dental procedure;
• Gingivitis, periodontitis, or gum disease of any kind.
• Dental procedures other than those stated above.
• Replacement of existing crowns, inlays, fillings, bridges or missing teeth apparent at the start
date of the policy.
EXTRACTION OF WISDOM TEETH - A 6 MONTH WAIT PERIOD AND A 10% CO-INSURANCE
APPLIES TO THIS BENEFIT - PRE-AUTHORISATION REQUIRED FOR IN-PATIENT TREATMENT.
Extraction of buried, impacted or un-erupted wisdom teeth on an in-patient, day-patient or out-
patient basis.
ORTHODONTIC TREATMENT - A 6 MONTH WAIT PERIOD AND A 10% CO-INSURANCE APPLIES
TO THIS BENEFIT
Orthodontic dental treatment for insured children under age 19.
Full Refund
Not Covered
Not Covered
Not Covered
Not Covered
Evolution Health Plan| StandardPage 6 of 9HDI/UK/EVO/TOB-STAN/04/21
B
C
D
7 Maternity Benefits A 10 MONTH WAIT PERIOD APPLIES AND PRE-AUTHORISATION IS REQUIRED
A COMPLICATIONS OF PREGNANCY AND CHILDBIRTH
The costs of treatment for all pre-natal care; delivery costs; hospital accommodation for the
newborn immediately following birth; and post natal care for the mother, where complications
occur during the pregnancy or childbirth. For the purposes of this policy complications of
pregnancy and childbirth will only be deemed to include the following: toxaemia, gestational
hypertension, pre-eclampsia, ectopic pregnancy, hydatidiform mole, ante and post-partum
haemorrhage, retained placenta membrane, stillbirths, miscarriage, caesarean sections (where a
physician has certified that it is medically necessary) and abortions (where a physician has certified
it is medically necessary).
Please note that no cover is available for:
• Terminations of pregnancy on non-medical grounds.
• Ante-natal classes and midwifery costs when not directly associated with the childbirth
delivery.
• Treatment received by the newborn after the initial paediatric check up unless the newborn is
added to the insured persons policy within 14 days of birth.
• There is no cover for the pregnancy, delivery or newborn where the pregnancy has been
conceived using any form of assisted reproduction (including in vitro fertilisation) under this
benefit.
NORMAL PREGNANCY AND CHILDBIRTH
The costs of treatment for all pre-natal care; delivery costs; hospital accommodation for the
newborn immediately following birth; and post-natal care for the mother.
Please note that no cover is available for:
• Terminations of pregnancy on non-medical grounds.
• Ante-natal classes and midwifery costs when not directly associated with the childbirth
delivery.
• Treatment received by the newborn after the initial paediatric check up unless the newborn is
added to the insured persons policy within 14 days of birth.
• There is no cover for the pregnancy, delivery or newborn where the pregnancy has been
conceived using any form of assisted reproduction (including in vitro fertilisation) under this
benefit.
PAEDIATRIC BENEFIT
Contribution towards the costs of an initial paediatric check-up for the newborn.
There is no cover for the pregnancy, delivery or newborn where the pregnancy has been conceived using
any form of assisted reproduction (including in vitro fertilisation) under this benefit.
PREMATURE BABY TREATMENT
The costs of medical treatment for a premature baby where received during the first 2 months
following birth.
Please note that no cover is available:
• Where the baby has not been added to the insured persons policy within 14 days of birth.
• For continuing treatment after the expiry of the initial 2 month period other than for new and
unrelated medical conditions.
• Treatment received by the newborn after the initial paediatric check up unless the newborn is
added to the insured persons policy within 14 days of birth.
• There is no cover for the pregnancy, delivery or newborn where the pregnancy has been
conceived using any form of assisted reproduction (including in vitro fertilisation) under this
benefit.
Not Covered
Not Covered
Not Covered
Not Covered
B
C
D
7 Maternity Benefits A 10 MONTH WAIT PERIOD APPLIES AND PRE-AUTHORISATION IS REQUIRED
A COMPLICATIONS OF PREGNANCY AND CHILDBIRTH
The costs of treatment for all pre-natal care; delivery costs; hospital accommodation for the
newborn immediately following birth; and post natal care for the mother, where complications
occur during the pregnancy or childbirth. For the purposes of this policy complications of
pregnancy and childbirth will only be deemed to include the following: toxaemia, gestational
hypertension, pre-eclampsia, ectopic pregnancy, hydatidiform mole, ante and post-partum
haemorrhage, retained placenta membrane, stillbirths, miscarriage, caesarean sections (where a
physician has certified that it is medically necessary) and abortions (where a physician has certified
it is medically necessary).
Please note that no cover is available for:
• Terminations of pregnancy on non-medical grounds.
• Ante-natal classes and midwifery costs when not directly associated with the childbirth
delivery.
• Treatment received by the newborn after the initial paediatric check up unless the newborn is
added to the insured persons policy within 14 days of birth.
• There is no cover for the pregnancy, delivery or newborn where the pregnancy has been
conceived using any form of assisted reproduction (including in vitro fertilisation) under this
benefit.
NORMAL PREGNANCY AND CHILDBIRTH
The costs of treatment for all pre-natal care; delivery costs; hospital accommodation for the
newborn immediately following birth; and post-natal care for the mother.
Please note that no cover is available for:
• Terminations of pregnancy on non-medical grounds.
• Ante-natal classes and midwifery costs when not directly associated with the childbirth
delivery.
• Treatment received by the newborn after the initial paediatric check up unless the newborn is
added to the insured persons policy within 14 days of birth.
• There is no cover for the pregnancy, delivery or newborn where the pregnancy has been
conceived using any form of assisted reproduction (including in vitro fertilisation) under this
benefit.
PAEDIATRIC BENEFIT
Contribution towards the costs of an initial paediatric check-up for the newborn.
There is no cover for the pregnancy, delivery or newborn where the pregnancy has been conceived using
any form of assisted reproduction (including in vitro fertilisation) under this benefit.
PREMATURE BABY TREATMENT
The costs of medical treatment for a premature baby where received during the first 2 months
following birth.
Please note that no cover is available:
• Where the baby has not been added to the insured persons policy within 14 days of birth.
• For continuing treatment after the expiry of the initial 2 month period other than for new and
unrelated medical conditions.
• Treatment received by the newborn after the initial paediatric check up unless the newborn is
added to the insured persons policy within 14 days of birth.
• There is no cover for the pregnancy, delivery or newborn where the pregnancy has been
conceived using any form of assisted reproduction (including in vitro fertilisation) under this
benefit.
Not Covered
Not Covered
Not Covered
Not Covered
Evolution Health Plan| StandardPage 7 of 9HDI/UK/EVO/TOB-STAN/04/21
9 Cash Benefits
A
A
B
B
C
CONGENITAL BENEFIT - A 12 MONTH WAIT PERIOD APPLIES TO THIS BENEFIT
For conditions not discovered at birth but which can subsequently be corrected with surgery.
A maximum lifetime limit applies to this benefit.
This benefit is only available if the insured person has been covered on the policy since birth.
CONGENITAL/BIRTH DEFECTS BENEFIT
For conditions diagnosed within one year of birth for babies conceived by natural means.
A maximum lifetime limit applies to this benefit.
This benefit is only available if the insured person has been covered on the policy since birth.
HOSPITAL CASH BENEFIT
The amount payable when in-patient treatment has been received free of charge within the
provision of a state run national health service for which no claim is made/paid under any other
item of this policy.
If you make a claim under this benefit of the policy you are unable to make a further claim under any
other benefit on the policy for the same medical condition.
MATERNITY CASH BENEFIT – A 10 MONTH WAIT PERIOD APPLIED TO THIS BENEFIT
The amount payable on the birth of each child subject to the child being born at least 10 months
after the mother’s start date. This benefit is only payable where no claim for pregnancy and/or
childbirth has been made/paid against any other item of this policy.
Please note that notification of the addition of a newborn does not constitute a formal claim submission
for this benefit.
If you make a claim under this benefit of the policy you are unable to make a further claim under any
other benefit on the policy for the same medical condition.
CONVALESCENCE CASH BENEFIT
The amount payable for each complete week of confinement to home (excluding the first week),
on the instruction of the treating consultant, immediately following a period of in-patient hospital
treatment for a medical condition covered by this policy. Limited to 4 weeks per period of
insurance.
If you make a claim under this benefit of the policy you are unable to make a further claim under any
other benefit on the policy for the same medical condition.
Not Covered
50 per night –
maximum 30
nights
Not Covered
Not Covered
Not Covered
2,5008 Additional Benefits
C INFERTILITY BENEFIT – A 12 MONTH WAIT PERIOD APPLIES TO THIS BENEFIT
Investigations into the medical cause of infertility, where both members are insured under this
policy and when the couple’s treating physician believes there are symptoms and/or evidence to
suggest a medical cause.
Please note that no cover is available:
• For medical treatment for infertility, or any other related condition, once a medical cause has
been identified.
Not Covered
9 Cash Benefits
A
A
B
B
C
CONGENITAL BENEFIT - A 12 MONTH WAIT PERIOD APPLIES TO THIS BENEFIT
For conditions not discovered at birth but which can subsequently be corrected with surgery.
A maximum lifetime limit applies to this benefit.
This benefit is only available if the insured person has been covered on the policy since birth.
CONGENITAL/BIRTH DEFECTS BENEFIT
For conditions diagnosed within one year of birth for babies conceived by natural means.
A maximum lifetime limit applies to this benefit.
This benefit is only available if the insured person has been covered on the policy since birth.
HOSPITAL CASH BENEFIT
The amount payable when in-patient treatment has been received free of charge within the
provision of a state run national health service for which no claim is made/paid under any other
item of this policy.
If you make a claim under this benefit of the policy you are unable to make a further claim under any
other benefit on the policy for the same medical condition.
MATERNITY CASH BENEFIT – A 10 MONTH WAIT PERIOD APPLIED TO THIS BENEFIT
The amount payable on the birth of each child subject to the child being born at least 10 months
after the mother’s start date. This benefit is only payable where no claim for pregnancy and/or
childbirth has been made/paid against any other item of this policy.
Please note that notification of the addition of a newborn does not constitute a formal claim submission
for this benefit.
If you make a claim under this benefit of the policy you are unable to make a further claim under any
other benefit on the policy for the same medical condition.
CONVALESCENCE CASH BENEFIT
The amount payable for each complete week of confinement to home (excluding the first week),
on the instruction of the treating consultant, immediately following a period of in-patient hospital
treatment for a medical condition covered by this policy. Limited to 4 weeks per period of
insurance.
If you make a claim under this benefit of the policy you are unable to make a further claim under any
other benefit on the policy for the same medical condition.
Not Covered
50 per night –
maximum 30
nights
Not Covered
Not Covered
Not Covered
2,5008 Additional Benefits
C INFERTILITY BENEFIT – A 12 MONTH WAIT PERIOD APPLIES TO THIS BENEFIT
Investigations into the medical cause of infertility, where both members are insured under this
policy and when the couple’s treating physician believes there are symptoms and/or evidence to
suggest a medical cause.
Please note that no cover is available:
• For medical treatment for infertility, or any other related condition, once a medical cause has
been identified.
Not Covered
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