GROUP LIFE INSURANCE

INSURANCE TERMS & CLAUSES

Group Life insurance is the provision of financial assistance after death, to the beneficiaries of

insured employees (except in the case of suicide in the first two years of coverage).

BASIS OF COVERAGE:

Flat Sum

Coverage is maintained either at similar levels for all employees or at varying levels for each category

of employees. The levels may be revised annually or periodically. Some employers choose this

method for ease of budgeting and confidentiality.

Salary Multiple

Coverage is calculated by multiplying the annual salary by the formula of coverage. The formula

varies from once to five times annual salary. A minimum of twice annual salary is recommended.

When this method is applied, all salary changes must be advised to ensure accurate sums insured.

Coverage is reduced by 50% at retirement or age 65, whichever is earlier.

Conversion Privilege

Terminating employees may apply for conversion of Group Life coverage to personal policies,

without evidence of insurability. However, such applications must be made within 31 days of

termination of employment.

Disability Benefit

In the event of total and permanent disability before age 60, the Insurance will continue at no cost, for

as long as the employee remains totally disabled.

Extended Death Benefit

If an employee dies during 31 days after termination of employment, the death benefit, which would

have been applicable prior to termination of employment, would be paid.

Accidental Death & Dismemberment (AD&D)

AD&D is insurance protection against accidental death or injury and is only offered to active

employees. The sum insured for accidental death is usually similar to the Group Life Coverage.

Coverage for dismemberment is a percentage of the principal sum insured.

GROUP HEALTH INSURANCE

INSURANCE TERMS & CLAUSES

Group Health Insurance is designed to provide assistance to full time employees and their eligible

dependents with the cost of medical care in respect of services arising from illness, accident and

pregnancy.

When does coverage commence?

Coverage begins on the 1st day of the next month coincident with completion of your probationary

period and is available to all full time permanent employees between the ages of 18 and retirement

age (coverage continues beyond retirement in cases where a pensioner’s plan is in effect).

Actively at Work Clause:

This clause states that coverage/benefit changes will not become effective unless the employee is

“actively at work” when the change becomes effective. This includes any period of approved leave of

absence by the University, provided that the counter-part funding by the employee. There is a

fourteen (14) days waiting period for coverage of newborns.

Who are eligible dependents?

A dependent is classified as the spouse (opposite sex), married or unmarried of an employee, and

children of the union, step-children, foster children and legally adopted children who are between the

ages of 14 days and 19 years. Children who continue to be full time students at an accredited

institution after attainment of age 19 may continue to be covered up to age 23, by providing

verification of full time student status to the Insurer on an annual basis.

How are Maternity Benefits handled?

The benefits outlined in the schedule are available to all female employees and covered dependent

spouses. The maximum benefits stated include ante-natal visits, delivery fees, lab tests and x-rays

occurring directly as a consequence of pregnancy, hospitalization for mother and baby. All these

expenses are claimable only from the Maternity Benefit up to the stated maximums. Major Medical

is not applicable to Maternity unless there are complications of pregnancy.

- Examples:

- Hyperemesis Gravidarum

- Eclampsia (Toxemia with convulsions)

- Extra-Uterine pregnancy

Dental

Dental benefit includes an oral examination & prophylaxis (cleaning) every six months in addition to

fillings.

Excluded are:

- Orthodontic procedures (braces)

- Cosmetic procedures

- Gold restorations

- Bridge work

Elective restorative procedure (crowns - except stainless steel)

Optical

The optical benefit covers eye examination, frames and lenses, these are available from the health

plan based on the following schedule:

- Eye examination - once every 12 months.

- Frames - one set every 24 months.

- Lenses– one pair every 12 months.

Contact Lens are treated as in lens above.

What is Major Medical?

Major Medical is the provision of additional protection to meet the expenses of serious illnesses,

accidents, and complications of pregnancy. These benefits combine with the Basic plan benefits to

offer a more comprehensive coverage for major illnesses and accidents without which an insured

would incur significant out of pocket expenses. Major Medical extends to coverage of all reasonable

medical expenses and operates on a coinsurance basis, with the plan covering 80% of costs and the

insured meeting the balance of 20%.

What is a Deductible?

In order to benefit from Major Medical, an insured’s out of pocket expenses after payment on the

basic plan must be greater than the deductible set out in the schedule of benefits. The deductible can

best be described as a toll that takes you from the Basic plan side of a bridge over to the Major

Medical side of the bridge. It can be satisfied by an accumulation of eligible out of pocket expenses

during a contract year, or from a single out of pocket expense. This deductible is satisfied only once

per contract year, per covered person. However, if two or more family members are injured in the

same accident, only one deductible is applied.

What is Maximum Lifetime Benefit?

This is the total benefit afforded each covered member, by the Insurer, during the lifetime of the

individual. The maximum may be restored if the Insured provides to the Insurer, satisfactory medical

evidence that he/she has been cured of the particular illness. Such evidence must be provided within

90 days of payment of the last claim in connection with the particular disability. Provision of the

requisite medical report will be at the expense of the insured.

What is UCR?

This is an abbreviation of Usual Customary and Reasonable charges, which is applied by each

Insurance Company primarily to Surgical and Hospitalization charges. It refers to a charge for

medical care which is considered reasonable and customary to the extent that it does not exceed the

general level of charges being made by others of similar standing in the locality where the charge is

incurred, when furnishing comparable treatment or services, to individuals of the same sex and

comparable age, for a similar disease or injury.

Overseas Emergency Benefit

This is a rider to the medical policy. As the name implies, it is insurance for emergencies that occur

outside of Jamaica. In the event of an emergency, you are required to contact the Managed Care

Provider by dialing the toll free number provided on the sticker which will be affixed to your card.

By doing so, you will be advised of the participating provider nearest to you that is qualified to deal

with your emergency. Provided you follow these steps, and your diagnosis is categorized as an

emergency, you pay nothing, as long as the charges fall below US$100,000.00. This is an annual

benefit.

An emergency is defined as a sudden onset of a life threatening condition that requires immediate

treatment. Treatment is intended to stabilize you so that you can return to your country of residence

for continuing or follow-up care. The benefit ceases after 31 consecutive days outside Jamaica. This

means, therefore, that the Overseas Emergency benefit does not apply to dependent children who are

attending tertiary institutions outside of Jamaica. Coverage for emergency treatment must commence

prior to the expiration of the 31st day of your trip overseas.

Overseas Non Emergency

Pre-authorization is required for this benefit. If the insured is referred overseas for treatment, pre-

authorization is based on non-availability of the treatment for the stated condition in Jamaica. This

benefit is limited to the insured’s Life Time Maximum.

Over-age Dependent

Coverage for a dependent child who is over 19 years and attending an accredited tertiary institution

on a full time basis, is available up to age 23. A letter is required from the institution every

September verifying that the child is still enrolled as a full time student.

HOSPITAL ROOM RATES

CATEGORY PRIVATE SEMI-PRIVATE WARD

MEDICAL ASSOCIATES $9,500.00 $7,500.00 $6,500.00

NUTTALL $7,000.00 $5,500.00 N/A

ST. JOSEPH $5,800.00 $4,200.00 $3,600.00

ANDREWS HOSPITAL $9,500.00 $7,500.00 N/A

TONY THWAITES $10,000.00 $8,000.00 N/A

DOCTOR’S SURGICAL

CLINIC $12,500.00 N/A N/A

HARGREAVES MEMORIAL

HOSPITAL $9,000.00 $8,500 N/A

MOBAY HOPE HOSPITAL N/A $8,500.00 (local patient)

US $350.00 (overseas Patient) N/A

Private All private rooms are air conditioned

Semi-private Two persons in a room sharing bathroom

Ward Four persons share a room

CLAIM GUIDELINES

In order to ensure speedy and accurate processing of health claims the following guidelines should be

adhered to:

MEMBER CLAIMS

The top section of the claim form should be completed providing accurate information about

the Insured/Patient and signature affixed.

Particulars pertaining to Providers of services; diagnosis, procedure and the name of the

referring physician should be given.

A detailed breakdown of charges and the amounts paid by the patients must be indicated

where necessary

Claim form must be stamped, dated and certified by the Provider (Doctor/Dentist)

Original receipt(s) must accompany claim forms

Claims MUST be submitted within 90 days from the date of service for claim to be eligible.

In addition to copies of the claims, all Coordination of Benefit (COB) claims, must be

accompanied by the payment summary from the Primary Carrier.

Pharmacy Claims are to be stamped, dated and signed by a Registered Pharmacist. The

Prescribing Doctor’s name must be indicated on the receipt.

Claims for Specialist Consultations should include the name and address of the referring

doctor.

Elective surgical procedures, CT Scans and MRI’s require Pre-authorization to determine

eligibility etc.

GENERAL INFORMATION

Alterations to claim forms using correction fluid will not be accepted.

Stale dated claims will be returned and not paid.

Claims for drugs dispensed in the Doctors’ Office will not be paid

Claims for Optical Consultation must include a diagnosis.

Only 30 days supply of maintenance medication should be dispensed at any one time.

The Provider of the service must be licensed and registered to operate in the field of service

provided.

The name, designation and registration number of the provider should be clearly indicated on

the claim form.

PROVIDER CLAIMS

All sections of the claim form must be accurately completed with the following information:

Provider #,

Date of Service

Certificate #

Group Policy Number

Health Card ID #

Employee’s Name

Referring Doctor

Diagnosis / RX# / Tooth #

Quantity of Drugs Dispensed

Description of Service provided

Breakdown of Disposable Items (Hospital)

Item Cost (Drug Claims)

Total Charges

Amount paid by patient (payment)

Patient / Dependent signature

Provider’s stamp, Designation, Registration # & Signature

GENERAL INFORMATION

The Provider of the service must be licensed to operate in the field of service provided and

the name and designation clearly identified on the claim form.

Pharmacy Claims are required to be stamped, dated and signed by a Registered

Pharmacist. The Prescribing Doctor’s name must be indicated on the claim form.

Claims must be submitted within 90 days from the date of service.

All Coordination of Benefit (COB) claims must be accompanied by the payment summary

from the Primary Carrier.

Optical Consultation Claims, outside of Vision Care (i.e. Lens & Frames) must be

completed with diagnosis.

NATIONAL HEALTH FUND

The National Health Fund is a statutory organization officially established in October 2003, with the

mission of reducing the burden of healthcare in Jamaica. They provide both individual and

institutional benefits.

NHF benefits are provided for prescription drugs that are predetermined by the Agency. In addition

there are subsidies for devices for the management of diabetes such as: test strips lancelets and

syringes. Glucometers used to measure sugar levels and Penfill applicators used to deliver insulin

dosage are available to cardholders of the NHF.

Benefits are available to all residents of Jamaica, regardless of age, income or gender, who are

diagnosed with the following listed illnesses.

Cancer

Breast cancer

Prostate cancer

Cardiovascular

Hypertension

Ischemic Heart Disease

Rheumatic Heart Disease

High Cholesterol

Vascular Disease

Central Nervous System

Epilepsy

Major Depression

Psychosis

Endocrine

Diabetes

Genito-Urinary

Benign Prostatic Hyperplasia

Optical

Glaucoma

Respiratory

Asthma

Musco-Skeletal

Arthritis

In order to benefit from the NHF, the individual, must be certified by a registered doctor as having

one or more of the specified medical conditions and complete the enrolment form. A copy of the Tax

Registration (TRN) is required for all enrolees including infants.

The NHF will issue a card for the purchase of prescription drugs at 284 of the 317 pharmacies

registered island-wide.

CO-ORDINATION OF BENEFITS

The benefits under the NHF can be coordinated with the private health plan by presenting both cards

to the pharmacist.

For further information you may contact your Account Executive at Allied Insurance Brokers

or

The National Health Fund

6th

Floor North Tower,

25 Dominica Drive

Tel: 1-888-NHF-CARE

1-888-643-2273

NATIONAL INSURANCE SCHEME

THE CONTRIBUTION RATE IS 5% OF SALARY, BROKEN DOWN:

EMPLOYEE 2.5%

EMPLOYER 2.5%

4% GOES TO THE NATIONAL INSURANCE SCHEME, WHILE 1% GOES TO THE

NATIONAL HEALTH FUND.

THE FOLLOWING BENEFITS ARE AVAILABE UNDER THE NATIONAL INSURANCE

SCHEME (WEEKLY).

OLD AGE/INVALIDITY & WIDOW/WIDOWERS PENSION – FULL - $2,400.00

- 3/4 - $1,800.00

- 1/2 - $1,200.00

PLUS A FLAT RATE OF 6 CENTS FOR EVERY $13.00 OF CONTRIBUTION

DEPENDENT SPOUSE ALLOWANCE $ 800.00

ORPHAN’S/SPECIAL CHILDREN ALLOWANCE $4,200.00

SUGAR WORKERS PENSION $1,200.00

SPECIAL ANNIVERSARY PENSION $1,200.00

DISABLEMENT PENSION $320.00 -$3,200.00

MATERNITY ALLOWANCE MINIMUM WAGE

GRANTS AND OTHER BENEFITS

OLD AGE/INVALIDITY & WIDOW/WIDOWERS GRANT $40,000.00

ORPHAN’S/SPECIAL CHILDREN GRANT $48,000.00

FUNERAL GRANT $70,000.00

EMPLOYMENT INJURY DEATH BENEFIT $150,000.00

For more information contact the Division of Human Resources and Administration

Prepared on March 18, 2013