Terms of Service

1. Covered Services

The Scheme shall provide coverage strictly limited to healthcare services, treatments, diagnostics, procedures, medications, consumables, and other medical benefits expressly stated in the approved benefit package of the Scheme as may be revised from time to time.

Covered services shall be accessed only in accredited healthcare facilities and in accordance with applicable referral protocols, clinical guidelines, authorization procedures, and administrative processes issued by the Scheme.

The Scheme reserves the sole discretion to determine:

• what constitutes a covered service;
• the level, scope, and frequency of services covered;
• applicable exclusions, limitations, and ceilings; and
• approved service providers for delivery of covered care.

Any service obtained outside these requirements without prior authorization, where required, may not be eligible for payment.[cite: 1]

2. Non-Covered Services

Non-covered services include, but are not limited to, any healthcare service, medication, diagnostic test, procedure, specialist consultation, consumable, or medical supply that is not expressly included in the Scheme's approved benefit package.

Non-covered services may also include services that:

• are deemed experimental, cosmetic, elective, or non-essential;
• fall outside clinical guidelines or Scheme protocols;
• exceed approved frequency limits or utilization thresholds;
• are obtained without required referral or authorization;
• are requested for personal convenience rather than medical necessity.

The Scheme shall not be liable for payment or reimbursement of any non-covered service, regardless of whether such service is recommended, prescribed, or administered by an accredited healthcare provider.

3. Out-of-Pocket Financial Responsibilities

The enrollee acknowledges and agrees that financial responsibility for all non-covered services rests solely with the enrollee.

Where a non-covered service is recommended or required during treatment, the healthcare provider shall inform the enrollee of:

• the nature of the service;
• the clinical reason it is not covered under the Scheme; and
• the estimated cost implication prior to provision.

The enrollee agrees that:

• payment for such services shall be made directly to the healthcare provider or facility;
• the Scheme shall not be responsible for reimbursement of such expenses;
• refusal to pay for non-covered services may affect the continuity of care where clinically dependent services are involved, subject to medical ethics and emergency obligations.

3.1. Consent and Authorization for Non-Covered Services

No non-covered service requiring out-of-pocket payment shall be rendered without the informed consent of the enrollee.

Prior to provision of such services, the healthcare provider shall ensure that the enrollee:

• is informed in clear and understandable language;
• is given the opportunity to ask questions and receive clarification;
• understands that the service is not covered under the Scheme; and
• voluntarily agrees to bear the cost of the service.

The enrollee shall be required to sign a written consent, undertaking, or financial responsibility form before the service is provided. Such document shall serve as evidence of voluntary acceptance of financial liability.

4. Waiting Period for Pre-Existing Conditions

The enrollee warrants that all known medical conditions, illnesses, or ongoing treatments existing prior to enrollment have been fully disclosed at the time of application.

Coverage for pre-existing conditions shall be subject to the waiting period prescribed by the Scheme, which shall commence from the effective date of enrollment.

The Scheme reserves the right to verify medical history and may require supporting documentation or clinical assessment to determine eligibility for coverage after the waiting period.

5. Fraud, Misrepresentation, and False Declaration

The enrollee acknowledges that the Scheme relies on the accuracy and completeness of all information provided during enrollment and claim processing.

Accordingly, any of the following shall constitute a breach of these Terms:

• provision of false, misleading, or incomplete information;
• concealment of material medical history or identity information;
• impersonation or use of another person's identity;
• submission of falsified documents or claims;
• collusion with healthcare providers to defraud the Scheme; or
• any attempt to obtain benefits unlawfully.

Where fraud or misrepresentation is established or reasonably suspected, the Scheme reserves the right to:

• suspend or terminate enrollment immediately;
• deny current or future claims;
• recover any funds improperly paid; and
• refer the matter to appropriate regulatory, administrative, or law enforcement authorities for further action.

7. Acceptance of Terms

By clicking, the enrollee confirms that they have read, understood, and voluntarily agreed to be bound by these Terms and Conditions.

The enrollee further acknowledges that these Terms may be amended, updated, or revised by the Commission from time to time, and continued participation in the Scheme shall constitute acceptance of such amendments.