POLICY RULES
Terms, General Exclusions and Definitions
relating to your plan
Cigna Close Care
SM
CONTENTS
Please read these Policy Rules along with your Certificate of Insurance and your Customer Guide as
they all form part of your contract between you and us. If necessary seek expert advice should you
need to determine if this policy is appropriate for you.
Words and phrases in italics have the meanings given to them in Section 3, ‘Definitions’.
Please see below where to find all of the important information in relation to your
Cigna Close Care
SM
plan.
Legal and regulatory information Page 3
Complaints Page 3
How to contact us Page 3
Section 1: General terms and conditions Page 4
1. Scope of cover and policy eligibility................................................................................. 4
2. When does cover begin and end.......................................................................................5
3. The information you give us................................................................................................ 5
4. Free look period....................................................................................................................... 6
5. Premium and other charges................................................................................................ 6
6. Termination..................................................................................................................................6
7. Fraud.............................................................................................................................................. 8
8. Coverage options..................................................................................................................... 8
9. Deductible and Cost Share.................................................................................................. 9
10. Adding or removing beneficiaries....................................................................................9
11. Changes to country of habitual residence, address and/ornationality.............10
12. How we will communicate with you............................................................................... 11
13. Policy renewal.......................................................................................................................... 11
14. Data protection....................................................................................................................... 11
15. Who can enforce this policy............................................................................................. 12
16. Our right to recovery from third parties...................................................................... 12
17. Other Insurance.......................................................................................................................12
18. Changes to this policy.........................................................................................................12
19. Sanctions................................................................................................................................... 12
20. Pandemics, Epidemics and Infectious Illnesses........................................................13
Section 2: General exclusions Page 14
Section 3: Definitions Page 18
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LEGAL AND REGULATORY INFORMATION
For the purpose of this policy:
Cigna Insurance Management Services (DIFC) Limited which is regulated by the Dubai Financial
Services Authority is acting as an underwriting agent on behalf of Cigna Global Insurance Company
Limited.
This insurance is provided by:
Cigna Global Insurance Company Limited
PO Box 155, Mill Court
La Charroterie, St Peter Port
Guernsey GY1 4ET
Channel Islands
Cigna Global Insurance Company Limited is authorised and regulated in Guernsey by the Guernsey
Financial Services Commission for the conduct of insurance business.
This policy does not replace any state health insurance scheme. You may wish to take appropriate
advice before stopping contributions to any state health insurance scheme of which you are a
member.
COMPLAINTS
Any complaint should in the first instance be sent to us at the address in the ‘How to contact us’
section below.
If the complaint is not resolved, the complaint may be referred to the Financial Ombudsman at:
The Channel Islands Financial Ombudsman (CIFO)
PO Box 114, Jersey, Channel Islands
JE4 9QG
Telephone: +44 (0)1534 748610
Fax: +44 (0) 1534 747629
Email: [email protected]
The Financial Ombudsman Service can adjudicate most (but not all) complaints. Its decision is binding
on us but the person making the complaint may reject it without affecting their legal rights (including
their right to bring court proceedings).
Unless specifically agreed to the contrary, this policy is governed by, and will be interpreted in
accordance with, the law of England and Wales.
Any disputes about this policy, including disputes about its validity, formation and termination, will be
determined exclusively in the courts of England and Wales.
HOW TO CONTACT US
For full details, please see clause 6.7 of these Policy Rules. You will need to provide your policy
number, full name and email address used in the application form.
You can also write to us at the following address:
Cigna Global Health Options
Customer Care Team
1 Knowe Road, Greenock
Scotland
PA15 4RJ
In other circumstances you can call our Customer Care Team 24/7 on:
+44 (0) 1475 788 182 or from inside the USA on: 0800 835 7677.
SECTION 1: GENERAL TERMS
AND CONDITIONS
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1. Scope of cover and policy eligibility
1.1
This policy is only offered to beneficiaries
who are expatriates. Therefore, this policy
will only cover the costs of treatment in
a beneficiary’s country of nationality in
circumstances where the beneficiary is
temporarily resident in their country of
nationality. Such circumstances may not
exceed one hundred and eighty (180) days
in aggregate per period of cover, and the
country of nationality must be within the
area of coverage (see clause 11 for full
details).
The area of coverage for this policy is
restricted to your country of nationality
and your country of habitual residence
only, unless covered under the Out of Area
Emergency cover benefit. See clause 8.3 for
more details.
1.2
Subject to the terms, conditions, limits,
exclusions (and special exclusions as
detailed in your Certificate of Insurance, if
applicable) of this policy, Cigna will cover
you for medical and related expenses
relating to medically necessary treatment
which is recommended by a medical
practitioner, and provided within the area
of coverage for injury and sickness. The
treatment must occur during the period of
cover and deductibles, cost shares and limits
of cover may apply. In some circumstances
we may, at our absolute discretion, agree to
remove an exclusion if you pay an additional
premium. This will be agreed at the time you
purchase your policy.
1.3
This policy is subject to a condition limit
as detailed in the list of benefits. This is
the annual amount we will pay towards all
costs of treatment following the diagnosis
of a condition. This includes all claims paid
across inpatient, daypatient and outpatient
in relation to the primary condition. This
applies to each beneficiary per period of
cover. We will only pay for outpatient costs
if the Outpatient and Wellness Care option
has been selected, with the exception of
benefits which include outpatient treatment
as part of your Core cover.
We will not pay for any costs that exceed
the overall condition limit as detailed in the
list of benefits in the Customer Guide.
1.4
You must be eighteen (18) years old or over
at the time of purchase in order to purchase
this policy.
1.5
You must provide us with all of the
necessary customer identification
documentation or know your customer
documentation (for example a copy of
your passport and proof of address dated
within the last 3 months) that we may
request in relation to any beneficiary to
satisfy applicable anti-money laundering
regulations from time to time (including but
not limited to, any regulations issued by the
Dubai Financial Services Authority and the
Guernsey Financial Services Commission or
their successors):
1.5.1
Until we receive the requested know
your customer documentation outlined
in 1.5 we will not approve any treatment
under this policy, we will not issue any
guarantee of payment or settle any
claims for treatment costs in relation to
any beneficiary; and
1.5.2
A failure to provide us with the requisite
know your customer documentation
within thirty (30) days of the start date
will give rise to a right, exercisable by us,
to terminate this policy with immediate
effect or on such longer period of notice
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as we in our absolute discretion may
determine.
1.6
If there are any changes that occur between
your application and the initial start date of
your policy and any information that you
provided to us in your application changes
during this period, you must let us know.
We reserve the right to cancel the policy or
apply any additional premiums or exclusions
as a result of any change to your state of
health which you have notified us of before
the initial start date of the policy. If you fail
to inform us of any change to your state of
health during this period, we may treat this
as misrepresentation, which could affect
coverage under your policy or payment of
claims.
1.7
This policy will not cover any costs relating
to treatment received before the cover
starts, or after the cover ends (even if that
treatment was approved by us before the
cover ends).
2. When does cover begin and end
2.1
This policy is an annual renewable contract
with a minimum period of cover of three
(3) months and a maximum period of cover
of twelve (12) months. This means that,
unless it is terminated before the end date
or renewed, the cover will end one (1) year
after the start date.
2.2
Subject to clause 4, if this policy ends within
the first three (3) months of the initial start
date, any premium which has been paid in
relation to this policy will not be refunded.
If this policy ends after the first three (3)
months of the initial start date and before
the end date, any premium which has been
paid in relation to the period after cover has
ended will be refunded on a pro rata basis,
so long as no claims have been made or
yet to be submitted and no guarantees of
payment have been put in place during the
period of cover.
If this policy ends after the first three (3)
months of the initial start date and before
the end date and you have made claims
under it or you have received treatment not
reimbursed yet, you will be liable for the
remainder of any premium in respect of the
policy which are unpaid.
2.3
If you die, cover will end for all beneficiaries
unless a beneficiary contacts us within
thirty (30) days of the date of death as
shown in the Death Certificate. If any of
the beneficiaries would like to continue
coverage by becoming the policyholder,
and subject to our policy terms, they must
inform us within thirty (30) days and
must provide us with a copy of the Death
Certificate. If a beneficiary does not wish
to continue coverage as the policyholder,
all cover will end, and we will not make
any payments in relation to treatment or
services which are received on or after the
date on which the cover ends.
3. The information you give us
In deciding whether to accept this policy
and in setting the terms and premium, we
have relied on the information that you
have given to us. You must take care when
answering any questions that we ask by
ensuring that all information is accurate and
complete.
If we determine on reasonable grounds that
you deliberately or recklessly provided us
with false or misleading information, it could
adversely affect this policy and any claim.
For example, we may:
>
treat this policy as if it had never existed,
refuse to pay all claims and return the
premium paid. We will only do this if we
provide you with insurance cover which
we would not otherwise have offered;
>
amend the terms of your insurance. We
may apply these amended terms as if
they were already in place if a claim
has been adversely impacted by your
carelessness; or
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>
terminate in accordance with 6.2.
We will notify you in writing if any of the
above circumstances occur.
If you become aware that information you
have given us is inaccurate, you must inform
us as soon as possible using one of the
options in the ‘How to contact us’ section on
page 3 of these Policy Rules.
4. Free look period
You have a statutory right to cancel your
policy within fourteen (14) days from the
date you receive this policy. If you wish to
cancel this policy and we have not paid a
claim or issued a guarantee of payment, you
will receive a full refund of your premium.
Alternatively, if we have paid a claim, or
issued a guarantee of payment, we will not
refund any premium which has been paid.
To cancel this policy, please contact us using
one of the options in the ‘How to contact us’
section on page 3 of these Policy Rules.
If you do not exercise your right to cancel
this policy, it will continue in force for a
minimum period of three (3) months and
you will be required to make any premium
payments that are due to us.
For your termination rights outside of the
fourteen (14) day statutory cooling off
period, please refer to clause 6 of this policy.
5. Premium and other charges
5.1
Your Certificate of Insurance sets out the
premium and any other charges (such as
taxes) which are payable, and states when
and how they must be paid.
Payments must be made in the currency and
in the manner detailed in your Certificate of
Insurance.
5.2
If you, or any beneficiaries, do not seek prior
approval for treatment or receive treatment
in the USA at a hospital, clinic or medical
practitioner which is not part of the Cigna
network, we may not pay for all of your
treatment. Please see ‘Your Guide to Getting
Treatment’ on page 10 of the Customer
Guide for the details of how we will calculate
any reduction in the value of your claim. A
list of Cigna’s network of hospitals, clinics
and medical practitioners is available in your
secure online Customer Area.
Please note, we may, at our sole discretion
and without notification, make changes to
the Cigna network from time to time by
adding and / or removing hospitals, clinics,
medical practitioners and pharmacies.
5.3
If you do not pay premium and/or any other
charges when they are due, we will notify
you by email immediately and suspend
your policy i.e. cover for all beneficiaries
will be suspended. If payment is made, the
policy will be reinstated. We will not approve
treatment while the policy is suspended. We
will not settle any claim while any payment
to us is outstanding until the outstanding
amount is paid.
If after thirty (30) days the amount is
still outstanding, we will write to you
informing you that the policy is cancelled.
The cancellation date shall take effect on
the date when the first outstanding payment
was due.
If you settle the outstanding amount
within thirty (30) days of when the first
outstanding payment was due, we will
reinstate your cover back to that date.
5.4
Subject to clause 13, we will inform you of
the premium and any other charges which
will apply during the next period of cover.
The premium and/or other charges will
change each period of cover.
6. Termination
6.1
Subject to any conflicting legal or regulatory
requirements we will terminate this policy
for all beneficiaries immediately if:
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6.1.1
any premium or other charge (including
any relevant tax) is not paid in full within
thirty (30) days of the date on which it is
due. We will give you written notice if we
are going to terminate the policy for this
reason;
6.1.2
it becomes unlawful for us to provide
any of the cover available under this
policy or we are required to terminate
the policy in any particular jurisdiction or
territory at the direction of a regulator or
authority with competent jurisdiction; or
6.1.3
any beneficiary is identified on any list
imposing financial sanctions on targeted
individuals or entities maintained by the
United Nations Security Council, the
European Union, the United States Office
of Foreign Assets Control or any other
applicable jurisdiction. Furthermore, we
will not pay claims for services received
in sanctioned countries if doing so would
violate the requirements of the United
Nations Security Council, the European
Union or the United States Department
of Treasury’s Office of Foreign Assets
Control; or
6.1.4
you have failed to provide us with
the requisite know your customer
documentation requested pursuant
to clause 1.5 within thirty (30) days of
the start date (or such longer period of
time that we may have notified you in
writing), termination in accordance with
this clause 6.1.4 shall have immediate
effect although we will refund any
premiums you have paid.
6.2
Subject to clause 3, we will terminate this
policy with immediate effect if, we, at our
sole discretion determine, on reasonable
grounds, that you have, in the course of
applying for the policy or when making
any claim under it, withheld information
or knowingly or recklessly provided
information which you know or believe
to be untrue or inaccurate or failed to
provide information which we have asked
for, including medical information.
6.3
Subject to clause 11, we may terminate this
policy if any beneficiary ceases to be an
expatriate whether as a result of a change
to a beneficiary’s country of nationality or
country of habitual residence.
6.4
We may terminate this policy if we
reasonably believe you have travelled to a
country outwith your area of coverage for
treatment, unless covered under the terms
of clause 8.3.
6.5
We may terminate this policy if any
beneficiary relocates to a country which is
not your country of habitual residence.
6.6
If we are no longer in the market to sell
the policy or suitable alternative in your
geographical area, we will notify you at least
one (1) month before the end date to advise
you that the policy will be terminated (and
therefore unable to be renewed) with effect
from the end date.
6.7
If you want to terminate this policy and end
cover for all beneficiaries, you may do so at
any time by giving us at least fourteen (14)
days’ notice in writing. Termination of your
policy will take effect fourteen (14) days
after you, the policyholder, notifies us of the
request by using one of the options in the
‘How to contact us’ section on page 3 of
these Policy Rules.
6.7.1
If the policy is terminated in accordance
with clause 6.7, before the end date,
and we have paid a claim, covered a
treatment or issued a guarantee of
payment during the period of cover,
you will be liable for the remainder of
any premiums in respect of the policy
which are unpaid. If your annual premium
is collected at intervals throughout
the policy year, you will be responsible
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for making these payments for the
remainder of the period of cover or
alternatively, settle the outstanding
premium amount.
6.8
In relation to the period after your cover has
ended, unless your policy is terminated in
accordance with clause 6.2 and/or clause 7,
then any premium which has been paid in
relation to the period after cover has ended
will be refunded to the extent that it does
not relate to a period of time in which we
have provided cover, so long as we have not
paid any claim, or issued any guarantee of
payment during the period of cover.
6.9
If treatment has been authorised, we will not
be held responsible for any treatment costs
if the policy ends or a beneficiary leaves the
policy before treatment has taken place.
7. Fraud
7.1
If a beneficiary makes a fraudulent claim
under this policy, we:
i. are not liable to pay the claim;
ii. may recover from the beneficiary any
sums paid by us in respect of the claim;
and
iii. may give notice to the beneficiary
and treat the contract as having been
terminated with effect from the time of
the fraudulent act.
7.2
If we exercise our right under clause 7.1 (iii)
above:
i. we shall not be liable to the beneficiary
in respect of a relevant event occurring
after the time of the fraudulent act. A
relevant event is whatever gives rise to
our liability under this policy (such as the
occurrence of a loss, the submission of
a claim, or the notification of a potential
claim); and
ii. we do not need to return any of the
premium paid.
7.3
If this policy provides cover for any
beneficiary other than you, and a fraudulent
claim is made under this policy on behalf
of a beneficiary other than you, we may
exercise the right set out in clause 7.1 above
as if there were an individual insurance
contract between us and that beneficiary.
However, the exercise of any of those rights
shall not affect the cover provided under the
contract for any other beneficiary.
Nothing in this clause 7 is intended to vary
the position under the Insurance Act 2015.
8. Coverage options
8.1
If a beneficiary does not have cover under
the Outpatient and Wellness Care or Dental
Care and Treatment options, we will not pay
for any of the treatments which are available
under those options.
8.2
Coverage options cannot be changed at
your request during the period of cover
and can only be made upon renewal. If you
want to add or remove coverage options,
or reduce your deductible, cost share
or out of pocket maximum, we may ask
you to complete a new medical history
questionnaire, and we may apply new
special restrictions or exclusions on the new
coverage options. You should let us know
in writing at least seven (7) days before the
annual renewal date.
8.3
Beneficiaries will be covered for emergency
treatment on an inpatient or daypatient
basis or provided on an outpatient basis (if
the Outpatient and Wellness Care additional
coverage option has been purchased
under your policy) during temporary trips,
even if those trips are outside your area of
coverage. As with all emergency treatment,
if you have not purchased the Outpatient
and Wellness Care additional coverage
option, your emergency treatment will only
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be covered if it results in an admission to
the hospital. Please note, the health check
and screenings under the Outpatient and
Wellness Care option are not covered under
the Out of Area Emergency cover benefit.
This cover will be limited to a maximum
period of twenty-one (21) days per trip
and a maximum of forty-five (45) days per
period of cover for all trips combined and up
to the overall annual limit of the Out of Area
Emergency cover benefit. Any cost shares
or deductibles elected on your policy will
continue to apply.
To be eligible for this benefit the medical
condition requiring emergency treatment
must not have existed prior to the travel and
the beneficiary must have been treatment-,
symptom- and advice free of the medical
condition prior to initiating the travel.
Receiving medical treatment must not
have been one of the objectives of the trip.
Emergency treatment is only applicable
if you do not already have state-provided
healthcare in that country.
Proof of the date of entry into the country
outside your area of coverage will also be
required prior to benefits being paid under
this cover. This cover will cease once the
treatment provided results in a stabilised
condition.
9. Deductible and Cost Share
9.1
If you have selected a deductible on the
Core cover and/or Outpatient and Wellness
Care option (if applicable), you will be
responsible for paying the deductible
amount directly to the hospital, clinic,
medical practitioner or pharmacy. We will let
you know what this amount is.
We will reduce the amount which we will
pay towards the cost of treatment in respect
of each claim which is made under the Core
cover or Outpatient and Wellness Care
option (if applicable) by the amount of
any deductible until the deductible for the
period of cover is reached.
9.2
If you have selected a cost share on the
Core cover and/or Outpatient and Wellness
Care option (if applicable), we will reduce
the amount we pay towards the cost of
treatment by that cost share percentage.
You will be responsible for paying the cost
share directly to the hospital, clinic, medical
practitioner or pharmacy. The amounts you
pay are subject to the capping effect of the
applicable out of pocket maximum.
9.3
Only amounts you pay related to the cost
share on the Core cover and/or Outpatient
and Wellness Care option are subject to
the capping effect of the out of pocket
maximum. The following are not subject to
the out of pocket maximum:
>
Any amounts you pay due to a
deductible;
>
Due to exceeding limits of cover;
>
For treatment not covered by the Core
cover or Outpatient and Wellness Care
option; or
>
Due to penalties for not obtaining
prior approval or using out of network
providers in the USA.
Any amounts you pay to the deductible,
cost share and out of pocket maximum
where applicable, apply separately to each
beneficiary, each coverage option and each
period of cover.
9.4
No deductible applies to ‘Inpatient cash
benefit'.
10. Adding or removing beneficiaries
10.1
If you would like to add a new beneficiary
during the policy year, you must send us
a completed application for that person.
Acceptance of any new beneficiary is at
our sole discretion. We will advise you of
any special conditions or exclusions and
any additional premium that will apply
to the offer of cover. Cover for any new
beneficiary will begin from the date on
which you confirm your acceptance. We will
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send you an updated Certificate of Insurance
confirming that the new beneficiary has
been added.
The beneficiary’s area of coverage must be
the same as the policyholder’s, otherwise
the beneficiary must take out a separate
policy, or an alternative Cigna plan.
10.2
If a beneficiary gives birth, you may apply
to add the newborn as a beneficiary to
your existing plan. The newborn will be
subject to full medical underwriting and an
additional premium will be due. We will tell
you whether we will offer cover to the new
beneficiary, and if so, any special conditions
and exclusions which would apply. If you
accept the offered terms, cover will begin
from the date on which you confirm your
acceptance. We will send you an updated
Certificate of Insurance confirming that the
new beneficiary has been added.
11. Changes to country of habitual
residence, address and/ornationality
11.1
If any beneficiary changes their country
of habitual residence you must inform us
as soon as practicable and in any event
within thirty (30) days. We reserve the right
to ask you for further information about a
change in your or any other beneficiary’s
country of habitual residence from time
to time. Note that any change to your or
any other beneficiary’s country of habitual
residence may result in an increase to
your premium or additional tax becoming
payable, meaning you may have to make
an additional payment of premium or
your monthly or quarterly payments may
increase. If the premium increases, we will
give you the right to cancel the policy, in
accordance with clause 6.7, in which case
clauses 6.7.1, 6.8 and 6.9 will apply. Please
note that the insurance may be provided by
another Cigna group company.
11.2
If a beneficiary returns to their country of
nationality then the treatment which they
can obtain will be limited to one hundred
and eighty days (180) days in aggregate
during the policy year.
11.2.1
We reserve the right to review all
claims submitted by beneficiaries
in their country of nationality and
in circumstances where we know or
reasonably believe the beneficiary
is or intends to be resident in their
country of nationality in excess of
one hundred and eighty (180) days
in aggregate per period of cover. In
such circumstances we may no longer
consider that beneficiary to be an
expatriate as they have returned to their
country of nationality for a sustained
period and we may refuse payment of
any claim or issuance of a guarantee of
payment.
Please note, the country of nationality
where beneficiaries can obtain treatment
is the same as the policyholder’s country
of nationality.
11.3
If any beneficiary ceases to be an expatriate
whether as a result of a change to a
beneficiary’s country of nationality or
country of habitual residence, then you can
either:
11.3.1
leave the policy in force for the
remainder of the period of cover. You
must inform us upon renewal if you
cease to be an expatriate and we
will determine if we can offer you an
alternative health plan provided by
another Cigna group company; or
11.3.2
terminate the policy by giving written
notice with the effect that cover will end
for all beneficiaries. Any premium which
has been paid in relation to the period
after termination will be refunded to the
extent that it does not relate to a period
of time in which we have provided cover,
so long as we have not paid claims or
issued any guarantees of payment during
the period of cover.
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12. How we will communicate with
you
We will send any communication
and notices in relation to this policy
electronically to the email address you have
provided, and we will place your policy
documents in your secure online Customer
Area.
13. Policy renewal
13.1
If we determine to renew, we will write to
you at least one (1) calendar month before
the end date to invite you to renew on the
terms we offer you. We will inform you of
any changes to the policy and premium for
the forthcoming period of cover. If local
law and/or regulation dictates, we may be
required to offer you an alternative health
plan.
Subject to clause 7, any decision by Cigna
not to renew shall not be based on your
claims history or any illness, injury or
condition suffered by any beneficiaries.
13.2
If you accept the invitation to renew, please
ensure you have read and understood the
policy documents for the forthcoming
period of cover. Your cover will be renewed
for another twelve (12) months.
13.3
If you do not want to renew your cover, you
must let us know in writing at least fourteen
(14) days before your policy end date.
13.3.1
If you do not renew your cover, any
beneficiaries who have been covered
under the policy can apply for their own
cover. We will consider their applications
individually, and inform them whether,
and on what terms, we are willing to
offer them such cover.
13.4
If you would like to add or remove coverage
options, you must let us know in writing
at least seven (7) days before your annual
renewal date. We may apply new special
restrictions, exclusions and/or adjust
premium. If we do so we will send you an
updated Certificate of Insurance.
13.5
If any special exclusion(s) have been applied
to any beneficiary there may be occasions
when we can review them at a future annual
renewal date, to consider whether we are
willing to remove the exclusion. If this is the
case, we will show the exclusions review
date in the Certificate of Insurance. At such
date, we will also review the additional
premium (if any) which we may have applied
to cover a condition.
You should contact us upon receipt of the
renewal notification, and at least fourteen
(14) days before the annual renewal date if
there is an exclusion which is due for review
at that date.
We will then advise you of changes (if any)
we have made and, where appropriate,
issue an amended Certificate of Insurance.
Amendments will be effective from the
relevant annual renewal date. We do not
guarantee that any special exclusion(s) or
additional premium will be removed on
renewal.
14. Data protection
14.1
In assessing your application, and
administering the policy and the insurance
provided to you, we will collect, process
and share certain personal information
about you. We take your privacy very
seriously and we will always process your
information in accordance with applicable
data protection legislation, including the
General Data Protection Regulation (EU
2016/679), the Data Protection Law DIFC
Law No. 5 of 2020 and any other applicable
legislation and any guidance or codes of
practice issued in respect of protection of
personal data from time to time. For more
information please see our Data Protection
Notice, which we may update from time to
time.
12|www.cignaglobal.com
14.2
Cigna will for the purposes of administering
any claim, ask a beneficiary to provide
special category data relating to his or her
medical condition, previous conditions, state
of health and treatments.
15. Who can enforce this policy
Only we and you have legal rights in
connection with this policy. A person who is
not a party to this policy has no right under
the Contracts (Rights of Third Parties) Act
1999 to enforce any term of this contract but
this does not affect any right or remedy of a
third party which exists or is available apart
from that Act.
16. Our right to recovery from third
parties
If a beneficiary requires treatment as a result
of an accident or deliberate act for which
a third party is at fault, we (or any person
or company we nominate) will take on that
beneficiary’s right to recover the cost of
that treatment from the third party at fault
(or their insurance company). If we ask a
beneficiary to do so, he or she must take
all steps to include the amount of benefit
claimed from us under this policy in any
claim against the person at fault (or their
insurance company).
The beneficiary will need to sign and deliver
all documents or papers and take any other
steps we require to secure our rights. The
beneficiary must not take any action which
could damage or affect these rights. We can
take over and defend or settle any claim, or
prosecute any claim, in a beneficiary’s name
for our own benefit. We will decide how to
carry out any proceedings and settlement.
17. Other Insurance
If another insurer also provides cover, we
will negotiate with them as regards to who
pays what proportion of any claim. If a
beneficiary is covered by other insurance, we
may only pay part of the cost of treatment.
If another person, organisation or public
programme is responsible for paying the
costs of treatment, we may claim back any
of the costs we have paid.
18. Changes to this policy
18.1
No person other than an executive officer of
Cigna has authority to change this policy or
to waive any of its provisions on our behalf,
for example, sales representatives, brokers
and other intermediaries cannot vary or
extend the terms of the policy.
18.2
We reserve the right to make any changes
to this policy that are necessary to comply
with any changes to relevant laws and
regulations. If this happens, we will write to
you and tell you of the change.
19. Sanctions
It is Cigna’s global corporate policy to
comply with the economic sanctions
rules related to individuals, entities, and
countries applicable to its global business
operations, including but not limited to
those imposed by the United Nations, the
European Commission, the United States,
and Canada. Therefore, Cigna will not offer
coverage or pay benefits to or on behalf of,
any beneficiaries if doing so would violate
these sanctions rules. In the event that
Cigna learns that a sanctioned individual or
entity is enrolled under the policy, or that
a beneficiary becomes sanctioned, Cigna
will take all appropriate action, which could
include blocking, reporting, and terminating
coverage. Cigna is under no obligation to
notify the beneficiary in advance of taking
these actions, or to obtain licenses from
any government to enable the extension of
coverage in compliance with sanctions laws.
In addition, restrictions will apply to claims
incurred in sanctioned countries where there
is no relevant, approved license from the U.S.
Office of Foreign Assets Control. Among the
restrictions, Cigna will not cover: (1) elective
or pre-scheduled treatment in sanctioned
countries; or (2) beneficiaries considered
“ordinarily resident” in a sanctioned country.
Beneficiaries are considered ordinarily
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resident if they visit a sanctioned country for
a period of longer than six (6) weeks over
the course of any twelve (12) month period.
20. Pandemics, Epidemics and
Infectious Illnesses
20.1
We will cover medically necessary
treatment for disease or illness resulting
from a pandemic, epidemic or outbreak
of infectious illness, as defined by the
World Health Organisation (WHO). The
medically necessary treatment and related
medical conditions will be covered on an
inpatient, daypatient and outpatient (if the
Outpatient and Wellness Care option has
been selected) basis as per the benefits of
your plan and according to the terms of the
policy. Where prescribed drugs cannot be
accessed in the beneficiary’s current location
as a result of a pandemic, epidemic or
outbreak of infectious illness, we will cover
the shipment cost in addition to the cost of
the prescribed drugs under the terms of the
prescribed drugs and dressings outpatient
benefit.
20.2
We will cover medically necessary testing
for pandemic, epidemic or outbreak of
infectious illness, on an outpatient basis, in
line with policy coverage for diagnostics for
other illnesses, and according to the World
Health Organisation (WHO) guidelines.
20.3
When an approved vaccine becomes
available in a location through the local
social security programmes or governmental
agency, we recommend that local
government advice is followed and the local
health system or government programme is
accessed where available.
If the vaccine needs to be delivered in an
authorised private setting, and your plan
includes coverage for clinically appropriate
vaccines, then the vaccine will be covered
on an outpatient basis according to the
terms of the policy, and subject to the
appropriate local regulatory authorities
deeming the vaccine to be safe and efficient
in the country where it will be administered.
We cannot guarantee the availability
of a vaccine in any location and Cigna
cannot control how or when any vaccine is
distributed.
SECTION 2: GENERAL EXCLUSIONS
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We will not offer cover or pay claims when
it is illegal for us to do so under applicable
laws. Examples include but are not limited
to, exchange controls, local licensing
regulations or trade embargo.
In accordance with clause 19, we will not
cover any beneficiaries or pay claims in
jurisdictions when doing so would violate
applicable trade restrictions, including but
not limited to: restrictions imposed by the
United States Department of Treasury’s
Office of Foreign Assets Control; the
European Union Commission, or; the
United Nations Security Council Sanctions
Committees.
We cannot be held responsible for any loss,
damage, illness and/or injury that may occur
as a result of receiving medical treatment
at a hospital or from a medical practitioner,
even when we have approved the treatment
as being covered.
The following exclusions apply to your
policy. Please also refer to the list of benefits
detailed in the Customer Guide, including
the notes section for any further restrictions
and exclusions that apply, in addition to
the General Exclusions. Please also refer to
your Certificate of Insurance for any special
exclusions that may apply.
1. Treatment which is provided by:
a) a medical practitioner who is not
recognised by the relevant authorities
in the country where the treatment is
received as having specialist knowledge
of, or expertise in, the treatment of the
disease, illness or injury being treated;
b) a medical practitioner, therapist, hospital,
clinic, or facility to whom we have
given written notice that we no longer
recognise them as a treatment provider.
Details of individuals, institutions and
organisations to whom we have given
such notice may be obtained by calling
our Customer Care Team; or
c) a medical practitioner, therapist, hospital,
clinic, or facility which, in our reasonable
opinion, is either not properly qualified
or authorised to provide treatment, or is
not competent to provide treatment.
2. Treatment for:
a) a pre-existing condition; or
b) any condition or symptoms which result
from, or are related to, a pre-existing
condition.
We will not pay for treatment for a
pre-existing condition of which the
policyholder was (or should reasonably have
been) aware at the date cover commenced,
and in respect of which we have not
expressly agreed to provide cover.
3. Preventative treatment, including but
not limited to health screening, routine
health checks and vaccinations (unless
that treatment is available under one of
the options under which a beneficiary has
cover).
We will pay for preventative surgery when a
beneficiary:
a) has a significant family history of a
disease which is part of a hereditary
cancer syndrome (such as ovarian
cancer); and
b) has undergone genetic testing which has
established the presence of a hereditary
cancer syndrome. (Please note that we
will not pay for the genetic testing).
4. Treatment which is provided by anyone
who lives at the same address as the
beneficiary, or who is a member of the
beneficiary’s family.
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5. Treatment which is necessary as a result
of conflict or disaster including but not
limited to:
a) nuclear or chemical contamination;
b) war, invasion, acts of terrorism, rebellion
(whether or not war is declared), civil
war, commotion, military coup or other
usurpation of power, martial law, riot,
or the act of any unlawfully constituted
authority;
c) any other conflict or disaster events;
where the beneficiary has:
i) put him or herself in danger by entering
a known area of conflict (as identified
by a Government in your country of
nationality, for example the British
Foreign and Commonwealth Office);
ii) actively participated in the conflict; or
iii) displayed a blatant disregard for their
own safety.
6. Any treatment outside your country of
habitual residence or country of nationality
(area of coverage), unless the treatment
can be covered under the ‘Out of Area
Emergency cover’ benefit as detailed in
clause 8.3.
7. Travel costs for treatment including
any fares such as taxis or buses, unless
otherwise specified, and expenses such as
petrol or parking fees.
8. Any expenses for ship to shore
evacuations.
9. Treatment in nature cure clinics, health
spas, nursing homes, or other facilities which
are not hospitals or recognised medical
treatment providers.
10. Charges for residential stays in hospital
which are arranged wholly or partly for
domestic reasons or where treatment is
not required or where the hospital has
effectively become the place of domicile or
permanent abode.
11. Costs of hospital accommodation for a
deluxe, executive or VIP suite.
12. Any prosthetic device or appliance,
including but not limited to hearing aids and
spectacles, which is not medically necessary
and/or does not fall within our definition of
prosthetic device(s).
13. Incidental costs including newspapers,
telephone calls, guests’ meals and hotel
accommodation.
14. Costs or fees for filling in a claim form or
other administration charges.
15. Non-medical admissions or stays in
hospital which include:
a) treatment that could take place on a
daypatient or outpatient basis;
b) convalescence;
c) admissions and stays for social or
domestic reasons e.g. washing, dressing
and bathing.
16. Life support treatment (such as
mechanical ventilation) unless such
treatment has a reasonable prospect of
resulting in the beneficiary’s recovery,
or restoring the beneficiary to his or her
previous state of health.
17. Foetal surgery, i.e. treatment or surgery
undertaken in the womb before birth
or treatment by way of the intentional
termination of pregnancy, unless the
pregnancy endangers a beneficiary’s life or
mental stability, and any other maternity
treatments including complications arising
from maternity.
18. Footcare by a Chiropodist or Podiatrist.
19. Treatment for, or in connection with,
smoking cessation.
20. Treatment that arises from, or is in any
way connected with attempted suicide,
or any injury or illness that the beneficiary
inflicts upon him or herself.
21. Developmental problems, treatment
for personality and/or character disorders,
including but not limited to:
16|www.cignaglobal.com
a) learning difficulties such as dyslexia;
b) autism and attention deficit
hyperactivity disorder (ADHD);
c) physical development problems such as
short height;
d) affective personality disorder;
e) schizoid personality disorder; or
f) histronic personality disorder.
22. Disorders of the temporomandibular
joint (TMJ).
23. Treatment for a related condition
resulting from addictive conditions and
disorders.
24. Treatment for a related condition
resulting from any kind of substance or
alcohol use or misuse.
25. Treatment needed because of, or relating
to, male or female birth control, including
but not limited to:
a) surgical contraception, namely:
>
vasectomy, sterilisation or implants;
b) non-surgical contraception, namely:
>
pills or condoms;
c) family planning, namely:
>
meeting a doctor to discuss
becoming pregnant or contraception.
26. Treatment for sexual dysfunction
disorders (such as impotence) or other
sexual problems regardless of the
underlying cause.
27. Treatment which is intended to
change the refraction of one or both eyes,
including but not limited to laser treatment,
refractive keratotomy and photorefractive
keratectomy. Note that we will pay for
treatment to correct or restore eyesight if
it is needed as a result of a disease, illness
or injury (such as cataracts or a detached
retina).
28. Gender reassignment surgery, including
elective procedures and any medical or
psychological counselling in preparation
for, or subsequent to, any such surgery,
unless state or federal law requires such
coverage. We will cover medically necessary
behavioural health services, including
but not limited to, counselling for gender
dysphoria and related psychiatric conditions
(such as anxiety and depression) and
medically necessary hormonal therapy.
29. Treatment which is necessary because
of, or is any way connected with, any injury
or sickness suffered by a beneficiary as a
result of:
a) taking part in a sporting activity at a
professional level;
b) taking part in a hazardous sporting
activity or hobby, including but not
limited to off-piste winter sports, base
jumping, tombstoning or cliff jumping,
mountaineering or rock climbing,
potholing, motorsports, equestrian
sports (for instance horse racing or
jumping, polo, or hunting), bull riding or
bull running, parkour;
c) solo scuba-diving; or
d) scuba-diving at a depth of more than
thirty (30) metres unless the beneficiary
is appropriately qualified (namely PADI
or equivalent) to scuba-dive at that
depth.
30. Treatment which (in our reasonable
opinion) is experimental, or has not been
proven to be effective. This includes but is
not limited to:
a) treatment which is provided as part of a
clinical trial;
b) treatment which has not been approved
by the relevant public health authority in
the country in which it is received; or
c) any drug or medicine which is prescribed
for a purpose for which it has not been
licensed or approved in the country in
which it is prescribed.
31. Any form of cosmetic or reconstructive
treatment and any complication thereof,
the purpose of which is to alter or improve
appearance even for psychological reasons,
unless that treatment is medically necessary
and is a direct result of an illness or an injury
suffered by the beneficiary, or as a result of
surgery.
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32. Treatment that is in any way caused
by, or necessary because of, a beneficiary
carrying out an illegal act.
33. Donor organs:
a) mechanical or animal organs, except
where a mechanical appliance is
temporarily used to maintain bodily
function whilst awaiting transplant;
b) purchase of a donor organ from any
source; or
c) harvesting and storage of stem cells, as
a preventative measure against possible
future disease.
34. Sleep disorders unless there are
indications that the beneficiary is suffering
from severe sleep apnoea. In these
circumstances, we will only pay for:
a) one (1) sleep study; and
b) the hire of equipment such as a
Continuous Positive Airway Pressure
(CPAP) machine (only if the beneficiary
has cover under the Outpatient and
Wellness Care option).
If it is medically necessary, we will pay for
surgery.
35. Treatment for obesity, or which is
necessary because of obesity. This includes,
but is not limited to, slimming classes, aids
and drugs.
We will only pay for gastric banding or
gastric bypass surgery if a beneficiary:
a) has a body mass index (BMI) of 40 or
over and has been diagnosed as being
morbidly obese;
b) can provide documented evidence of
other methods of weight loss which have
been tried over the past twenty-four (24)
months; and
c) has been through a psychological
assessment which has confirmed that it
is appropriate for them to undergo the
procedure.
36. Treatment relating to infertility (other
than investigation to the point of diagnosis),
fertility treatment of any sort, or treatment
of complications arising as a result of such
treatment. This includes, but is not limited
to:
a) in-vitro fertilisation (IVF);
b) gamete intrafallopian transfer (GIFT);
c) zygote intrafallopian transfer (ZIFT);
d) artificial insemination (AI);
e) prescribed drug treatment;
f) embryo transportation (from one
physical location to another); or
g) ovum and/or semen donation and
related costs.
We will pay for investigations into the cause
of infertility if:
a) the specialist wishes to rule out any
medical cause;
b) the beneficiary has been covered under
this policy for two (2) consecutive
years before the investigations have
commenced; and
c) the beneficiary was unaware of the
existence of any infertility problem,
and had not suffered any symptoms,
when their cover under this policy
commenced.
37. Treatment directly related to surrogacy.
38. Any expenses in relation to international
emergency medical evacuation or
repatriation services.
39. Treatment directly or indirectly related
to abnormalities, deformity, disease, illness
or injury present at birth (congenital
conditions) whether evident or not at the
moment of childbirth.
SECTION 3: DEFINITIONS
The words and phrases set out below have the meanings specified. Where those words and phrases
are used with those meanings, they will appear in italics in these Policy Rules, and in the Customer
Guide, including the list of benefits.
Unless otherwise provided, the singular includes the plural and the masculine includes the feminine
and vice versa.
18|www.cignaglobal.com
Annual renewal date - the anniversary of the
start date.
Application - the policyholder’s application
(whether they have sent in a form directly
to us or through a broker or applied online
or through our telemarketers), and any
declarations that they made during their
enrolment for them and any beneficiaries
included in the application.
Appropriate age intervals - child and
adolescence age schedule up to age seventeen
years old as set out by the American Academy
of Pediatrics (AAP).
Area of coverage - your country of habitual
residence and your country of nationality. For
the avoidance of doubt this is the policyholder’s
country of habitual residence and country of
nationality.
Beneficiaries, beneficiary - anybody named in
your Certificate of Insurance as being covered
under this policy, including newborn children.
Certificate of Insurance - the certificate issued
to the policyholder. This shows the policy
number, the annual premium, the start date,
the deductible amount (if selected), the cost
share amount (if selected), the out of pocket
maximum (if applicable), details of who is
covered, any special exclusions or exclusions
that have been removed at an additional
premium and the health plan and selected
options (if applicable) which apply.
Cigna, we, us, our, the insurer - see page 3
of these Policy Rules for details of the Cigna
insurer providing your policy.
Clinic(s) - a health care facility which is
registered or licensed in the country in which
it is located, primarily to provide care for
outpatients and where care or supervision is by
a medical practitioner.
Condition(s) - any disease, illness or injury a
beneficiary is diagnosed with.
Core cover - includes all aspects of inpatient
and daypatient treatment included in the list
of benefits. This does not include the optional
modules which you may choose.
Cosmetic - services, procedures or items that
are supplied primarily for aesthetic purposes
and which are not necessary in order to
maintain an acceptable standard of health.
Country of habitual residence - the country
where all beneficiaries habitually reside, as
stated in your application.
Country of nationality - the country of which
you are a citizen, national or subject, as stated
in your application.
Daypatient - a patient who is admitted to a
hospital or daypatient unit or other medical
facility for treatment or because they need a
period of medically supervised recovery, but
who does not occupy a bed overnight. This also
includes surgical procedures carried out in a
doctor’s surgery.
Dentist - dental surgeon or dental practitioner
who is registered or licensed as such under the
laws of the country, state or other regulated
area in which the treatment is provided.
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Doctor - a medical professional who is
registered and licensed under the laws
of the country, state or regulated area to
practice medicine in the country in which
the treatment is provided.
Emergency treatment - treatment which
is medically necessary to prevent the
immediate and significant effects of
illnesses, injuries or conditions which, if
left untreated, could result in a significant
deterioration in health. Only medical
treatment through a physician, medical
practitioner and hospitalisation that
commences within twenty four (24) hours of
the emergency event will be covered.
End date - the date on which cover under
this policy ends, as shown in the Certificate
of Insurance.
Evidence-based treatment - treatment
which has been researched, reviewed and
recognised by:
>
the National Institute for Health and Clinical
Excellence; or
>
International Clinical Guidelines.
Expatriate - means a beneficiary residing
outside the country of which they are a
national, in the country of habitual residence
as stated in your application.
Formulary drugs list - A prescription drugs
list applicable to all pharmacy claims in
the USA. This list is developed by Cigna
with assistance from our Pharmacy and
Therapeutics Committee and is updated
twice a year. All the medications included
in our formulary drugs list are approved
by the U.S. Food and Drug Administration
(FDA). Over-the-counter (OTC) medicines
(those that do not require a prescription),
except insulin, are excluded from our
formulary drugs list, unless state or federal
law requires coverage of such medicines. We
will notify you of any change that affects the
coverage of a medication that you are taking
at the time of any update.
Guarantee of payment - a binding
guarantee made by us to pay a provider
the agreed costs associated with a
particular treatment which we may give to
a beneficiary or a hospital, clinic or medical
practitioner.
Hospital - any organisation or institution
which is registered or licensed as a medical
or surgical hospital in the country in which it
is located and where the beneficiary is under
the daily care or supervision of a medical
practitioner or qualified nurse.
Initial start date - the first day the
beneficiary’s cover commenced on the Core
cover.
Injury - a physical injury.
Inpatient - a patient who is admitted to
hospital and who occupies a bed overnight
or longer, for medical reasons.
Medically necessary/ medical necessity -
medically necessary covered services and
supplies are those determined in accordance
with International Clinical Guidelines by the
medical team to be:
>
required to diagnose or treat an illness,
injury, disease or its symptoms;
>
orthodox, and in accordance with generally
accepted standards of medical practice;
>
clinically appropriate in terms of type,
frequency, extent, site and duration;
>
not primarily for the convenience of the
beneficiary, physician or other hospital, clinic
or medical practitioner; and
>
rendered in the least intensive setting that is
appropriate for the delivery of the services
and supplies.
Where applicable, the medical team
may compare the cost effectiveness of
alternative services, settings or supplies
when determining what the least intensive
setting is.
Medical practitioner - a doctor or specialist
who is registered or licensed to practice
medicine under the laws of the country,
state or other regulated area in which
the treatment is provided, and who is
not covered under this policy, or a family
member of someone covered under this
policy.
20|www.cignaglobal.com
Outpatient - a patient who attends a
hospital, consulting room, or outpatient
clinic for treatment and is not admitted as a
daypatient or an inpatient.
Period of cover - the twelve (12) months
continuous period during which the
beneficiaries are covered under this policy,
being the period from the start date to
the end date as noted in the Certificate
of Insurance or earlier if terminated in
accordance with the Policy Rules.
Personal Data - any information relating to
an identified or identifiable natural person.
Policy - the policy comprising these
Policy Rules, the Customer Guide (which
contains the list of benefits and claiming
information), and your Certificate of
Insurance.
Policy documents - the documentation
relating to the policy, comprising of these
Policy Rules, the Customer Guide, your
Certificate of Insurance and your Cigna ID
Card.
Policyholder - a person who is aged 18 years
or older who has made an application to us
which has been accepted in writing by us,
and who pays the premium under the policy.
Policy Rules - the terms and conditions,
general exclusions and defined terms that
govern this policy.
Pre-existing condition - any disease, illness
or injury, or symptoms present before the
initial start date linked to such disease,
illness or injury for which:
>
medical advice or treatment has been sought
or received; or
> the beneficiary knew about and did not seek
medical advice or treatment.
Prosthetic device(s) - an artificial limb or
tool which is required for the purpose of, or
in connection with surgery; or is a necessary
part of the treatment immediately following
surgery for as long as required by medical
necessity; or which is medically necessary
and is part of the recuperation process on a
short-term basis.
Qualified nurse - a nurse who is registered
or licensed as such under the laws of the
country, state or other regulated area in
which the treatment is provided.
Rehabilitation - physical, speech and
occupational therapy for the purpose of
treatment aimed at restoring the beneficiary
to their previous state of health after an
event.
Special category data - personal data
revealing racial or ethnic origin, political
opinions, religious or philosophical beliefs
or trade union membership, genetic data,
biometric data for the purpose of uniquely
identifying a natural person, data concerning
health and data concerning a person’s sex
life or sexual orientation.
Spouse - a beneficiary’s legal husband or
wife, or unmarried or civil partner who we
have accepted for cover under this policy.
Start date - the date on which coverage
under this policy starts, as shown in the
Certificate of Insurance.
Surgery - the branch of medicine that
treats diseases, injuries, and deformities
by operative methods which involves an
incision into the body.
Therapist - a speech therapist, dietician
or orthoptist who is suitably qualified and
holds the appropriate license to practice in
the country where treatment is received.
Treatment - any surgical or medical
treatment controlled by a medical
practitioner that is medically necessary
to diagnose, cure or substantially relieve
disease, illness or injury.
USA - the United States of America and US
territories.
You, your - the policyholder.
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NOTES
For policies arranged through our Dubai International Finance Centre office, under insurance license Cigna Global Insurance Company Limited, the underwriting agent is
Cigna Insurance Management Services (DIFC) Limited which is regulated by the Dubai Financial Services Authority.
“Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All
products and services are provided by or through such operating subsidiaries, and not by Cigna Corporation. Such operating subsidiaries include Cigna Global Insurance
Company Limited, Cigna Life Insurance Company of Europe S.A.–N.V., Cigna Europe Insurance Company S.A.-N.V. and Cigna Worldwide General Insurance Company
Limited. © 2022 Cigna. All rights reserved.
Cigna Close Care
SM
Policy Rules CGIC EN 10/2022
