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FREQUENTLY ASKED QUESTIONS

When does my cover end?

The contract of coverage is usually for one year from your start date unless otherwise stated in the policy document.

Can i change my level of cover, or change to a different plan at a later date?

Yes. You can add more benefits (called 'Riders') to your cover but at an additional premium. You cannot remove benefits. Similarly, you can only upgrade to a higher health plan. You cannot change to a lower plan. A health plan upgrade can take place at any time during the year of coverage.

What differentiates individual cover from group cover?

First, an individual cover is not entitled to a waiver of pre-enrollment medical examination. Secondly, the benefits of chronic medication and HIV management are not covered under individual plans at the quoted premium. An additional premium might be required.

Do i have an individual cover or group cover?

You have group coverage if you were enrolled as a member of an organization or company with at least 10 principal insured persons. You have individual coverage if you enrolled as a person or as a single-family.

What won't my policy cover?

See Exclusions List.

What does my policy cover?

See covered services under your preferred health plan.

If i do not use any of the services for the entire year, do I get a refund?

No, you will not get a refund. However, you will be entitled to a good discount if you wish to renew the policy for another year. It is good to remember that illness is often an unforeseen event and one may never know when a health insurance cover will be immensely useful.

What happens if the cost of services rendered to me exceeds the premium i paid?

Each health plan has a medical limit which is approximately seven times the premium paid (see your health policy document). You will not be required to make any refunds as long as you do not exceed your limit. When you utilize up to your medical limit before the expiration of your policy, you will be expected to pay for all subsequent services accessed for the remaining duration of your cover.

Do i have to pay any charges at The Point Of Service?

For covered services under most of the health plans, the answer is no. However, if a co-payment or deductible applies, you would be duly informed at the time of your application. For non-covered services that you request for, the Provider may ask you to pay out-of-pocket.

How can i access specialist Doctors?

You can see a specialist doctor, like a pediatrician or dental surgeon, at any time but through a referral by your Primary Care Provider. He/She decides whether you need specialist attention and subsequently facilitates the process. For further clarification, please contact the Health Services Unit of SHTL.

What happens if i lose my card?

You will be expected to apply for a new membership card. Your application should state your name, the health plan you are currently subscribed to, and your primary care provider. It must be accompanied by a sworn affidavit of loss and a recent passport photo. You will also be required to pay a processing fee.

What happens if i forget my card?

You are encouraged to always carry your card in your wallet/purse. If you forget your card, you can be able to access care at your primary care provider's (PCP). When you say your name and HMO, the PCP front desk will identify you using a photo form in their records. Unfortunately, apart from your PCP, you may not be able to access care anywhere else under the scheme without your membership ID card.

Can a friend or relative make use of my card with my consent?

No. Your membership ID card bears your photo and will not give access to care to anyone that does not match the photo. This is the reason every member of a subscribing family is issued a personal identity card.

Can i change my primary healthcare provider after joining?

Yes but you will need to have spent at least 3 months with the provider to be eligible to change. You may be required to furnish reasons for change. Where the decision is due to dissatisfaction, a formal complaint would have been lodged with SHTL at least one month prior to the application for change. The change if approved will take effect from the 1st day of the month succeeding the month of application.

Can i choose more than one hospital?

Yes! Every enrollee is entitled to one provider. However, if members of the family reside in different locations, you can choose a different provider for them.

Will my pre-existing conditions be covered?

Yes! However this is dependent on your chosen plan.

What plans are available?

We have five basic health plans namely SHTL Standard, SHTL Classic, SHTL Silver, SHTL Gold and SHTL Gold Plus. However, we are open to customization of plans based on your peculiar health needs.

Can i change my mind after i have joined?

Yes you can! With our carefully developed health plans, we are confident that our services will meet and surpass your needs. However, in the event that you change your mind, you can contact us via your relationship manager for further discussions.