Terms and Conditions

Welcome to Clinic Cover!

These terms and conditions outline the rules and regulations for the use of Clinic Cover’s Website, located at https://www.insuresmallsmall.com/policy-wording.

By accessing this website we assume you accept these terms and conditions. Do not continue to use Clinic Cover if you do not agree to take all of the terms and conditions stated on this page.

PREAMBLE:

The insurance cover provided under this Policy to the Insured / Insured Person up to the Sum Insured is and shall be subject to (a) the terms and conditions of this Policy and (b) the receipt of premium and (c) Disclosure to Information Norm (including by way of the Proposal or Information Summary Sheet) and (d) Schedule of Benefits.

SECTION 1 – DEFINITIONS:

Any word or expression to which a specific meaning has been assigned in any part of this Policy or the Schedule shall bear the same meaning wherever it appears. For purposes of this Policy, the terms specified below shall have the meaning set forth:

  • “Malaria” Malaria is an infection with malaria parasites that may result in a wide variety of symptoms, ranging from absent or very mild symptoms to severe disease and even death. Malaria disease can be categorized as uncomplicated or severe (complicated). In general, malaria is a curable disease if diagnosed and treated promptly and correctly.
  • Typhoid fever and paratyphoid fever are life-threatening illnesses caused by Salmonella serotype Typhi and Salmonella serotype Paratyphi, respectively. Typhoid can be controlled through vaccination (Oral or Injectable) * *https://www.cdc.gov
  • “Anyone Illness” means a continuous period of Illness and it includes relapse within 45 days from the date of the last consultation with the Hospital/Nursing Home where treatment may have been taken.
  • “Alternative Treatment” refers to the medical and/or hospitalization treatments given under ‘Herbal, Yoga and Naturopathy and Homeopathy
  • “Cashless facility” means a facility extended by the Insurer to the Insured where the payments of the costs of treatment undergone by the Insured in accordance with the Policy terms and conditions are directly made to the network provider by the Insurer to the extent pre-authorization
  • Company” means Farm box Micro insurance Limited T/A Insure Small Small.
  • Contribution” is essentially the right of an Insurer to call upon other Insurers, liable to the same Insured, to share the cost of an indemnity claim on a ratable proportion of Sum This clause shall not apply to any benefit offered on fixed benefit basis.
  • “Condition Precedent” shall mean a Policy term or condition upon which the Insurer’s liability under the Policy is conditional
  • “Congenital Anomaly” refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or
  • Internal Congenital Anomaly – Congenital Anomaly which is not in the visible and accessible parts of the body is called Internal Congenital Anomaly.
  • External Congenital Anomaly – Congenital Anomaly which is in the visible and accessible parts of the body is called External Congenital
  • “Cumulative Bonus” shall mean any increase in the Sum Insured granted by the Insurer without an associated increase in the premium.
  •  
  • “Day Care treatment” means medical treatment, and / or surgical procedure which is:
  • undertaken under general or local anesthesia in a hospital/day care center in less than 24 hours because of technological advancement, and
  • which would have otherwise required a hospitalization of more than 24
  • Treatment normally taken on an out-patient basis is not included in the scope of this definition.
  • “Day care Centre” means any institution established for day care treatment of Illness and / or injuries or a medical setup within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner and must comply with all minimum criteria as under:
  • has qualified nursing staff under its employment
  • has qualified medical practitioner/s in charge;
  • has a fully equipped operation theatre of its own where surgical procedures are carried out
  • maintains daily records of patients and will make these accessible to the Insurance Company’s authorized personnel.
  • “Dependent Child” means a child (natural or legally adopted), who is unmarried, aged between 91 days and 23 Months, financially dependent on the Insured and does not have his / her independent sources of income.
  • “Deductible” is a cost-sharing requirement applicable per event/claim under a health insurance Policy that provides, the Insurer will not be liable for a specified shilling amount in case of indemnity policies and /or for a specified number of days/hours in case of hospital cash benefit which will apply before any benefits are payable by the Insurer. A deductible does not reduce the Sum
  • “Disclosure to information norm” means the Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non- disclosure of any material
  • “Disease” means an alteration in the state of the body or of some of its organs, interrupting or disturbing the performance of the functions, and causing or threatening pain and weakness or physical or mental disorder and certified by a Medical
  • “Domiciliary hospitalization” means medical treatment for an Illness/Disease/Injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:
  • the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
  • the patient takes treatment at home on account of non-availability of room in a
  • Domiciliary hospitalization benefits shall be subject to the limits as specified in the Schedule to this Policy, and shall, in no case, cover expenses incurred for:
  • Pre and post Hospital treatment,
  • Treatment of any of the following Diseases:
  • Asthma;
  • Bronchitis;
  • Chronic nephritis and nephritic syndrome;
  • Diarrhea and all types of dysenteries including gastroenteritis;
  • Diabetes mellitus and insipidus;
  • Epilepsy;
  • Hypertension;
  • Influenza, cough and cold;
  • All psychiatric or psychosomatic disorders;
  • Pyrexia of unknown origin for less than 10 days;
  • Tonsillitis and upper respiratory tract infection including aryngitis and pharyngitis;
  • Arthritis, gout and
  • Diagnostic Tests” Investigations, such as X-Ray or blood tests, to find the cause of your symptoms and medical condition
  • “Emergency care” means management for a severe Illness or Injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long term impairment of the Insured person’s
  • “Family” means the Insured, his/her lawful spouse and maximum of three dependent children up to the age of 23 Months who are specifically covered under the Policy with their name, age, gender
  • Family Cover Policy” means a Policy in terms of which, two or more persons of a Family are named in the Schedule of Insurance Certificate as Insured Persons. In a Family Cover Policy, Family means a unit comprising of up to five members who are related to each other in the following manner:
  • Legally married husband and wife as long as they continue to be married; and/or
  • Up-to three of their children who are less than 23 Months on the date of commencement of the cover under the
  • “SMS” means Short Messaging Service as used by telecoms.
  • “USSD” means an application for sending and receiving information.
  • “Online App” means a technology application for access to information
  • Grace Period” means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a Policy in force without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases. Coverage is not available for the period for which no premium is received.
  • “Hospital” – A hospital means any institution established for in-patient care and day care treatment of Illness and/ or injuries and which has been registered as a hospital with the local authorities under the Ministry of Health or under the enactments specific to health centers or complies with all minimum criteria as under:
  • 22.1) has qualified nursing staff under its employment round the clock;
  • has at least 10 in-patient beds in towns having a population of less than 100,000 and at least 15 in-patient beds in all other places;
  • has qualified medical practitioner(s) in charge round the clock;
  • has a fully equipped operation theatre of its own where surgical procedures are carried out;
  • maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel.
  • “Hospitalization” means admission in a hospital for a minimum period of 24 in-patient care consecutive hours except for specified procedures/ treatments, where such admission could be for a period of less than 24 consecutive
  • “Illness” means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the Policy Period and requires medical
  • Acute condition – Acute condition is a disease, Illness or Injury that is likely to respond quickly to treatment that aims to return the person to his or her state of health immediately before suffering the disease/ Illness/ Injury which leads to full recovery.
  • Chronic condition – A chronic condition is defined as a disease, Illness, or Injury that has one or more of the following characteristics:
  • it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests;
  • it needs ongoing or long-term control or relief of symptoms;
  • it requires your/Insured person’s rehabilitation or for you/Insured member to be specially trained to cope with it;
  • it continues indefinitely;
  • it comes back or is likely to come back.
  • “Injury” means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent and visible, and evident means which is verified and certified by a Medical
  • “Inpatient care” means treatment for which the Insured person has to stay in a hospital for more than 24 hours for a covered
  • “Insured” means the primary Insured who has the highest age amongst other persons named in the Schedule of the Policy in case of Clinic Cover family Policy. In the case of an Individual Policy, the only member mentioned in the schedule of the policy shall be referred to as “Insured”.
  • “Insured Person” means the person named in the Schedule to the Policy and for whose benefit the insurance is proposed and appropriate premium paid. Insured Person is other than
  • Intensive Care Unit” means an identified section, ward, or wing of a hospital that is under the constant supervision of a dedicated Medical Practitioner(s), and which is specially equipped
  • Information Summary Sheet” means the record and confirmation of information provided to Company or Company’s representatives over the telephone for the purposes of applying for this
  • “Maternity expense” shall include
  • Medical treatment expenses were traceable to childbirth (including complicated deliveries and cesarean sections incurred during hospitalization).
  • Expenses towards lawful medical termination of pregnancy during the Policy
  • “Medical Practitioner” is a person who holds a valid registration from the Medical Council of Uganda or any other Council set up by the Government of Uganda and is thereby entitled to practice medicine within its jurisdiction and is acting within the scope and jurisdiction of license. The term Medical Practitioner includes a physician, specialist, and surgeon, provided that this person is not a member of the Insured/ Insured Person’s family who includes Father, Mother, Father-in-law, Mother-in-law, Son, Daughter, Son-in-law, Daughter-in-law, Brother or
  • “Medical expenses” means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been Insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.
  • “Medically Necessary” treatment is defined as any treatment, tests, medication, or stay in hospital or part of a stay in hospital which:
  • is required for the medical management of the Illness or Injury suffered by the Insured;
  • must not exceed the level of care necessary to provide safe, adequate, and appropriate medical care in scope, duration, or intensity;
  • 34.3) must have been prescribed by a medical practitioner,
  • 34.4) must conform to the professional standards widely accepted in international medical practice or by the medical community in Uganda.
  • “Medical Advice” means any consultation or advice from a Medical Practitioner including the issue of any prescription or repeat
  • Pharmacy/DrugShop” A pharmacy means any institution established for dispensing medications with/without prescription and which has been registered under the National Drug Authority as a Pharmacy or Drug shop.
  • New Born Baby” means a baby born during the Policy Period and is aged between 1 day and 90 days, both days inclusive.
  • “Network Provider” means hospitals or health care providers enlisted by an insurer or by a TPA and insurer together to provide medical services to an Insured on payment by a cashless
  • “Non- Network” means any hospital, daycare center or other providers that is not part of the
  • “Notification of claim” is the process of notifying a claim to the insurer or TPA by specifying the timelines as well as the address / telephone number to which it should be notified
  • “OPD treatment” is one in which the Insured visits a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient.
  • “Policy period” means the period between the inception date and the expiry date as specified in the Schedule to this Policy or the cancellation of this insurance, whichever is earlier.
  • “Policy” means this document of Policy describing the terms and conditions of this contract of insurance (basis the statements in the Proposal Form and the Information Summary Sheet), any annexure thereto, including the company’s covering letter to the Insured / Insured person if any, the Schedule attached to and forming part of this Policy and any applicable endorsement The Policy contains details of the scope and extent of cover available to the Insured/Insured Person, the exclusions from the scope of cover and the terms and conditions of the issue of the Policy.
  • “Policy Month” means the period of one Month commencing on the date of commencement specified in the Schedule of Insurance Certificate or any anniversary
  • “Portability” means transfer by an individual health insurance Policyholder (including family cover) of the credit gained for pre-existing conditions and time-bound exclusions if he/she chooses to switch from one Insurer to another.
  • “post-hospitalization Medical Expenses” means Medical Expenses incurred immediately after the Insured Person is discharged from the hospital provided that:
  • Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
  • The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance
  • “Pre-Existing Disease” means any condition, ailment or injury or related condition(s) for which you/Insured member had signs or symptoms, and/or were diagnosed, and/or received medical advice/treatment within 48 months prior to the first Policy issued by the
  • “Pre-hospitalization Medical Expenses” means medical expenses incurred immediately before the Insured Person is Hospitalized, provided that:
  • Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
  • The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance
  • “Qualified Nurse” is a person who holds a valid registration from the Nursing Council of Uganda or the Nursing Council of any district in Uganda.
  • “Renewal” defines the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of all waiting periods.
  • “Reasonable and Customary charges” means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the Illness / Injury
  • “Restoration of Sum Insured” means reinstatement of a hundred percent of the Sum
  • “Room rent” means the amount charged by a hospital for the occupancy of a bed on per day (24 hours) basis and shall include associated medical expenses.
  • “Schedule” means Schedule attached to and forming part of this Policy mentioning the details of the Insured/ Insured Persons, the Sum Insured, the period and the limits to which benefits under the Policy are subjects
  • “Schedule of Benefits” means the Product Benefits Table issued by the Company and accompanying this Policy and annexures
  • “Subrogation” means the right of the insurer to assume the rights of the Insured person to recover expenses paid out under the Policy that may be recovered from any other
  • 1.55)   “Sum Insured” means the sum as specified in the Schedule to this Policy against the name of Insured / each Insured Person at the inception of a Policy Month and in the event of Policy is upgraded or downgraded on any continuous Renewal, then exclusive of Cumulative Bonus, if any, the Sum Insured for which premium is paid at the commencement of the Policy Month for which the prevalent upgrade or downgrade is sought.
  • “Surgery” means Surgery or Surgical Procedure” means manual and/or operative procedure (s) required for treatment of an Illness or Injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed in a hospital or daycare center by a medical practitioner.
  • “Terrorism/Terrorist Incident” means any actual or threatened use of force or violence directed at or causing damage, injury, harm or disruption, or the commission of an act dangerous to human life or property or government, with the stated or unstated objective of pursuing economic, ethnic, nationalistic, political, racial or religious interests, whether such interests are declared or not. Robberies or other criminal acts, primarily committed for personal gain and acts arising primarily from prior personal relationships between perpetrator(s) and victim(s) shall not be considered terrorist activity. Terrorism shall also include any act, which is verified or recognized by the relevant Government as an act of
  • “Third Party Administrator (TPA)” means any organization or institution that is licensed by the IRA as a TPA and is engaged by the Company for a fee or remuneration for providing Policy and claims facilitation services to the Insured/ Insured Person as well as to the Company for an insurable
  • “Unproven/Experimental treatment” is treatment, including drug Experimental therapy, which is not based on established medical practice in Uganda, is treatment experimental or unproven.
SECTION 2 – SALIENT FEATURES & BENEFITS:
Basic cover up to the Sum Insured limit applicable to all plans:

The Company hereby agrees subject to the terms, conditions, and exclusions herein contained or otherwise expressed, to pay cashless and/or reimburse the following benefits in manner, for the period and to the extent of the Sum Insured as specified in the Schedule to this Policy.

The Policy covers Reasonable and Customary Charges incurred towards medical treatment taken during the Policy Period for an Illness, Accident or condition described below if this is contracted or sustained by an Insured Person during the Policy Period and subject always to the Sum Insured, any subsidiary limit specified in the schedule of Benefits, the terms, conditions, limitations and exclusions mentioned in the Policy and eligibility as per the insurance plan opted for in the schedule of Benefits and as shown in the Schedule of Insurance Certificate.

2.1)  Cashless Treatment:

This benefit provides cover for reimbursement/payment of cashless medicine access expenses up to the maximum benefit amount sustained by the Insured / Insured Person during the Policy period as specified in the Schedule to this Policy.

The Insured/Insured Person should have obtained a laboratory test and a Drs/medical practitioner’s drug prescription. The benefit under this Section is limited to the Sum Insured specified for this Section in the Schedule of Benefits to this Policy.

2.2)  Pre-medication diagnosis:

This benefit covers laboratory tests to confirm malaria and typhoid and a Drs./medical practitioners prescription as specified in the Schedule of benefits forming part of this Policy, prior to accessing the cashless pharmacy This benefit is a part of benefit available under Section 2.1 above and is limited to the available Sum Insured under Section 2.1. Pre-medication Expenses can be claimed as reimbursement only.

SECTION 3 – RENEWAL INCENTIVE:
 3.1 No Claim Cumulative Bonus:

 If no claim has been made in a 3 Month Policy window by any Insured / Insured Person, then for each subsequent Policy window Month, the Company will offer a no claim cumulative bonus as mentioned in Appendix III.

No claim bonus will be provided on the expiring Policy Sum Insured, provided that the Policy is renewed continuously for 3 consecutive months prior. The sub-limits applicable to various benefits will be doubled proportionately with the increase in Cumulative Bonus.

No Claim Cumulative Bonus will be calculated on the basis of Sum Insured of the last completed 3 Policy Months.

In case of a claim, the no claim bonus earned shall automatically expire in the same proportion in the following renewal of the Policy. This will not affect the Sum Insured of the Policy.

3.2  Portability:
i.    From the Company’s existing insurance policies to this Policy

 If the proposed Insured Person was insured continuously and without a break under another insurance policy with the Company, it is understood and agreed that:

    • If the Insured wish to exercise the Portability Benefit, the Company should have received the Insured’s application and completed Portability Form before the expiry of the existing insurance Policy;
    • This benefit is available only at the time of renewal of existing insurance
    • Portability benefit is available only up to the existing cover. If the proposed Sum Insured is higher than the Sum Insured under the expiring Policy, waiting periods would be applied on the amount of proposed increase in Sum Insured only, in accordance with the existing guidelines of the Insurance Regulatory
    • Waiting period credits would be extended to Pre-existing Diseases and time-bound exclusions/waiting periods in accordance with the existing guidelines of the Insurance Regulatory
    • The Portability Benefit shall be applied by the Company within 15 days of receiving Insured’s completed Application and Portability Form subject to the following:
      • Insured / Insured Person shall give the Company all additional documentation and/or information requests;
      • Insured / Insured Person pay the Company the applicable premium in full;
      • The Company may, subject to medical underwriting, restrict the terms upon which the company may offer cover, the decision as to which shall be in Company’s sole and absolute discretion;
      • There is no obligation on Company to ensure all Insured Persons or to ensure all Insured Persons on the proposed terms, even if Insured/ Insured person has given all
      • No additional loading or charges shall be applied by Company exclusively for porting the

The Company reserves the right to modify or amend the terms and the applicability of the Portability Benefit in accordance with the provisions of the regulations and guidance issued by the Insurance Regulatory Authority as amended from time to time.

SECTION 4 – EXCLUSIONS:
4.1 Waiting Period:
1.  8 days waiting period:

Expenses incurred for treatment undertaken for Disease or Illness within 8 days of the inception date of the first/initial Policy. This exclusion, however, doesn’t apply in the case of

  • Subsequent renewals with the Company without a
  • Portability to the extent of the waiting period and Sum Insured waived off in the Schedule of the
2.  Pre-existing Diseases / Illness / Injury / conditions:

The benefits will not be available for any condition(s) as defined in the Policy, until 48 months of continuous coverage have elapsed, since the inception of the first Policy with the Company.

Disclosure of any Pre-existing Diseases with details must to done at the time of application for this Policy/ addition of member in existing Policy, in the Proposal Form and shall be classified as pre-existing Disease post-acceptance of such application by the company.

B. The Company shall not be liable to make any payment for any claim directly or indirectly caused by or, based on or, arising out of or howsoever attributable to any of the following:
  1. War (whether declared or not) and warlike occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints, and detainment of all
  2. Any Illness or Injury directly or indirectly resulting from or arising from or occurring during the commission of any breach of any law by the Insured Person with criminal intent.
  3. Disease/ Illness/ Injury whilst performing duties as a serving member of a military or a police
  4. Any loss, Injury/Illness, directly or indirectly caused due to an act of terrorism or terrorist incident, regardless of any contributory causes (if the Company alleges that by reason of this exclusion any loss is not covered by this insurance, the burden of proving the contrary shall be upon the Insured / Insured Person).
  5. Expenses following Ionizing radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear
  6. Medical Treatment in respect of the Illness / Injury / Disease caused whilst engaging in speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing, potholing, abseiling, deep-sea diving, polo, snow and ice sports.
  7. Medical treatment in respect of the Injury caused whilst flying or taking part in aerial activities (including cabin crew) except as a fare-paying passenger in a regular Scheduled commercial airline
  8. Circumcision unless necessary for the treatment of a Disease, Illness or Injury not excluded hereunder, or, as may be necessitated due to an
  9. Dental treatment or surgery of any kind unless requiring hospitalization or in case of out-patient Dental Emergency Treatment (unless arising out of Accident only as specified under the scope of the Policy).
  10. Birth control procedures, hormone replacement therapy, contraceptive supplies or services including complications arising due to supplying services or Assisted Reproductive Technology, treatment arising from or traceable to pregnancy, childbirth including caesarean section and voluntary medical termination of pregnancy during the first 12 weeks from the date of conception. However, this exclusion will not apply to Ectopic Pregnancy proved by diagnostic means and certified to be life-threatening by the attending Medical Practitioner.
  11. Any treatment arising from or traceable to any fertility, infertility, sub-fertility or assisted conception procedure or
  12. Charges incurred in connection with cost of spectacles and/or contact lenses, hearing aids, routine eye and ear examinations, laser surgery for correction of refractory errors, dentures, artificial teeth and or all other similar external appliances and/or devices whether for diagnosis or treatment, Issue of medical certificates and examinations as to suitability for employment or
  13. Acquired Immune Deficiency Syndrome (AIDS), AIDS related complex syndrome (ARCS) and all Diseases / Illness / Injury caused by and/or related to HIV. Any condition directly or indirectly caused by or associated with venereal Disease, sexually transmitted Disease, including Genital Warts, Syphilis, Gonorrhea, Genital Herpes, Chlamydia, Pubic Lice and Trichomoniasis, Acquired Immuno Deficiency Syndrome (AIDS) whether or not arising out of HIV, Human T-Cell Lymphtropic Virus Type III (HTLV–III or IITLB-III) or Lymphadenopathy Associated Virus (LAV) or the mutants derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar
  14. Vitamins and tonics unless forming part of treatment for Disease, Illness or Injury as certified by the Medical
  15. Weight management services and or treatment, services and supplies including treatment of obesity (including morbid obesity),
  16. Any treatments related to sleep disorder, sleep apnoea syndrome, general debility, treatment received in convalescent homes, cure, rundown condition or rest cure, congenital internal and/or external Diseases / Illness or defects or anomalies, sterility, venereal Disease or intentional self- Injury
  17. Any treatment received in convalescent homes, convalescent Hospitals, health hydros, nature cure clinics or similar
  18. Medical Treatment following use/abuse of intoxicating drugs or alcohol or drug abuse, solvent abuse or any addiction or medical condition resulting from or relating to such abuse or
  19. Sex change or treatment, which results from, or is in any way related to, sex
  20. All preventive care vaccination including inoculation or immunization of any kind unless forming a part of post animal bite
  21. Treatment by a family member (Father, Mother, Father-in-law, Mother-in-law, Son, Daughter, Son-in-law, Daughter-in-law, Brother or Sister) and or self-medication or any treatment that is not scientifically
  22. Medical treatment required following involvement in any criminal act of the Insured / Insured
  23. Prostheses, corrective devices and medical appliances, which are not, required intra-operatively.
  24. Any stay in Hospital without undertaking any treatment or where there is no active regular treatment by the Medical
  25. Treatment of mental Disease / Illness, stress, psychiatric or psychological
  26. Aesthetic treatment, cosmetic surgery or plastic surgery unless necessitated due to Accident
  27. Experimental and unproven
  28. Charges incurred primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Disease, Illness or Injury.
  29. Cost incurred for medicines which are not under the advice of the Medical
  30. Any treatment which is taken as an out-patient without any admission as an in-patient at the Hospital except those that are specifically mentioned as covered specifically in this
  31. Costs of donor screening or treatment, unless specifically covered and specified in this
  32. Any treatment received outside
  33. Treatment taken from persons not registered as Medical Practitioners under respective medical
  34. Genetic disorders and stem cell implantation / Surgery or Growth Hormone
  35. Acupressure, acupuncture, magnetic
  36. Treatment for Age-Related Macular Degeneration (ARMD), treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy and Robotic
  37. Any kind of Service charges, Surcharges, Luxury Tax, and similar charges levied by the Hospital. (other than government taxes).
  38. External medical equipment of any kind used at home as post-hospitalization care including the cost of instrument used in the treatment of Sleep Apnoea Syndrome (C.P.A.P), Continuous Peritoneal Ambulatory Dialysis (C.P.A.D), and Oxygen concentrator for Bronchial Asthmatic
SECTION 5 – GENERAL CONDITIONS:

5.1 Duty of Disclosure:

The Policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, misdescription, or non-disclosure of any material facts in the Proposal Form, personal statement, declaration, and connected documents, or any material information having been withheld, or a claim is fraudulent or any fraudulent means or device being used by the Insured/Insured Person or anyone acting on their behalf to obtain a benefit under this Policy.

5.2)  Cover Policy:

Where the Policy is obtained on a cover basis covering the family members, the Sum Insured as specified in the Schedule to this Policy, shall be available to the Insured and all other Insured members. However, the Sum Insured shall be the overall limit including add-on Sum Insured unless otherwise specified, if opted and no claim bonus, if any for the entire period of Insurance/Policy period including all members/Insured persons and all claims.

5.3)  Reasonable Care:

The Insured/ Insured Person shall take all reasonable steps to safeguard the interests of themselves/ the Insured / Insured Person against accidental loss or damage or Illness or Injury that may give rise to a claim.

5.4)  Observance of terms and conditions:

The due observance and fulfillment of the terms, conditions, and endorsements of this Policy in so far as they relate to anything to be done or complied with by the Insured / Insured Person, shall be a condition precedent to any liability of the Company to make any payment under this Policy.

5.5)  Material Change:

The Insured / Insured Person shall immediately notify the Company in writing of any material change in the risk on account of change in nature of occupation or business, partial disclosure of the medical history at Insured / Insured person’s own expense. The Company may, adjust the scope of cover and/or the premium, if necessary, accordingly.

5.6)  Fraudulent Claims:

If any claim is in any respect fraudulent, or if any false statement or declaration is made or used in support thereof or if any fraudulent means or devices are used by the Insured / Insured Person or anyone acting on his/her behalf to obtain any benefits under the Policy, all benefits under this Policy shall be forfeited. The Company will have the right to reclaim all benefits paid in respect of a claim which is fraudulent as mentioned above under this condition as well as condition No. 7.1 of this Policy.

5.7)  No Constructive Notice:

The Company shall not take notice of any information relating to the Insured person unless such information is submitted in writing by the Insured, even if such information was available with the Company.

5.8)  Notice of Charge:

The Company is not under obligation to take note of any trust, assignment, lien or similar charge on or relating to the Policy. However, any payment by the Company to Insured or legal representative or bank shall be binding on all concerned and shall be considered as complete discharge by the Company.

5.9)  Special Provisions:

Any special provisions subject to which this Policy has been entered into and endorsed on the Policy or in any separate instrument shall be deemed to be part of this Policy and shall have effect accordingly.

5.10)  Overriding effect:

The terms and conditions contained herein and in the Schedule shall be deemed to form part of the Policy and shall be read as if they are specifically incorporated herein. The contents in the Policy Schedule shall have an overriding effect on Printed Policy wordings.

5.11)  Electronic Transaction:

The Insured / Insured Person agrees to adhere to and comply with all such terms and conditions as the Company may prescribe from time to time and hereby agrees and confirm that all transactions effected by or through facilities for conducting remote transactions including the internet, world wide web, electronic data interchange, call centers, teleservice operations (whether voice, video, data or combination thereof) or by means of electronic, computer, automated machines network or through other means of telecommunication established by or on behalf of the Company for and in respect of the Policy or its terms or the Company’s other products and services, shall constitute legally binding and valid transactions when done in adherence to and in compliance with the Company’s terms and conditions for such facilities, as may be prescribed from time to time. However, the terms of this condition shall not override provisions of any law(s) or statutory regulations including provisions of IRA regulations for the protection of the Policy holder’s interests.

  • Duty of the Insured on the occurrence of loss/event leading to claim

On the occurrence of loss/event/claim within the scope of cover under the Policy resulting in a claim, the Insured / Insured Person shall:

  1. Forthwith file/submit a claim form in accordance with “Claim Procedure”
  2. Allow the Medical Practitioner or any agent of the Company to inspect the medical and hospitalization records and to examine the Insured / Insured Person
  3. Assist and not hinder or prevent the Company or any of its agents in pursuance of their duties

In case the Insured / Insured Person does not comply with the provisions of this clause or other obligations cast upon the Insured / Insured Person under this Policy or in any of the Policy documents, all benefit under the Policy shall be forfeited, at the option of the Company.

5.13)  Right to Inspect:

If required by the Company, an agent/representative of the Company including a physician appointed on that behalf in case of any loss/event/claim or any circumstances that have given rise to a claim to the Insured / Insured Person, be permitted at all reasonable times to examine into the circumstances of such loss/event leading to claim. The Insured / Insured Person shall on being required so to do by the Company produce all relevant documents relating to or containing reference relating to the loss/event or such circumstance in his/her possession including presenting himself/herself for examination and furnish copies of or extracts from such of them as may be required by the Company so far as they relate to such claims or shall assist the Company to ascertain the correctness thereof or the liability of the Company under this Policy.

5.14)  Position after a claim:

As from the day of receipt of the claim amount by the Insured / Insured Person, the Sum Insured for the remainder of the Policy month of insurance shall stand terminated.

5.15)  Subrogation:

In the event of any claim payment under this Policy, the Company shall be subrogated to all the Insured/ Insured Person’s rights or recovery thereof against any person or organization, and the Insured/ Insured Person shall execute and deliver instruments and papers necessary to secure such rights. The Insured and any claimant under this Policy shall at the expense of the Company do and concur in doing and permit to be done all such acts and things as may be necessary and required by the Company, before or after indemnification, in enforcing or endorsing any rights or remedies or of obtaining relief or indemnity, to which the Company shall be or would become entitled or subrogated.

5.16)  Multiple policies & Contribution:

If two or more policies are taken by an Insured during a period from one or more Insurers to indemnify treatment costs, there will not be any contribution clause and the Insured can seek settlement of claim from any Insurer.

However, if the amount claimed is in excess of Sum Insured under a single Policy after considering the deductible and/or co-pay, Insured can seek settlement of claim as per his/ her choice but insurance Company shall settle the claim with contribution clause.

5.17)  Two Policy periods:

If the claim event falls within two Policy periods, the claim will be paid taking into consideration the available Sum Insured in the two Policy periods including the deductible for each policy period. Such eligible claim amount to be paid to the Insured shall be reduced by the amount of premium to be received for the renewal if not received earlier.

5.18)  Forfeiture of claims:

If any claim is made and rejected and no court action or suit is commenced within 5 days after such rejection or, in case of arbitration taking place as provided therein, within 5 working days after the arbitrator or arbitrators have made their award, all benefits under this Policy shall be forfeited and will not have any rights whatsoever.

5.19)  Free Look Period:

Insured has a period of 3 days from the date of receipt of the Policy document to review the terms and conditions of this Policy. If the Insured has any objections to any of the terms and conditions, he/she have the option of canceling the Policy stating the reasons for cancellation and in such a case, the Company will refund premium subject to

  • A deduction of the expenses incurred on any medical check-up, stamp duty charges, if the risk has not
  • A deduction of the expenses incurred on any medical check-up, stamp duty charges, and proportionate risk premium for the period on cover, if the risk has
  • A deduction of such proportionate risk premium commensuration with the risk covered during such period, where only a part of risk has commenced.

The Policy can be canceled only if Insured has not made any claims under the Policy. Freelook provision is not applicable and/or available at the time of renewal of the Policy.

5.20)  Grace Period:

All applications for renewal of the Policy must be received by us before the end of the Policy. A Grace Period of 1 day for renewing the Policy is provided under this Policy.

However, there is no coverage provided during the break period.

5.21)  Cancellation/Termination:

The Company may cancel this Policy, by giving 3 days notice in writing via SMS, email to the Insured at his / their last known address. The Company shall exercise its right to cancel only on grounds of misrepresentation, fraud, non-disclosure of material facts, or non-cooperation of the Insured / Insured Person in implementing the terms and conditions of this Policy, in which case the Company shall be liable to repay on demand a ratable proportion of the premium for the unexpired term from the date of the cancellation. The Insured may also give 3 days’ notice in writing, to the Company, for the cancellation of this Policy, in which case the Company shall from the date of receipt of the notice, cancel the Policy and retain the premium for the period this Policy has been in force at the Company’s short period scales given below. Provided that, refund on cancellation of Policy by the Insured shall be made only if no claim has/is occurred/reported up to the date of cancellation of this Policy / Policy riders.

Period on Risk

Rate of Premium to be retained by Company for 1 Month Policy

Rate of Premium to be retained by Company for 2 Months Policy

Rate of Premium to be retained by Company

for 3 Months Policy

Up to 1 month

100%

50%

25%

Exceeding 1 month Up to 3 months

75%

50%

25%

Exceeding 3 months Up to 6 months

75%

50%

25%

Exceeding 6 months Up to 12 months

75%

50%

25%

5.22)  Cause of action/Currency of payment:

No claim shall be payable under this Policy unless the cause of action arises in Uganda. All claims shall be payable in Uganda in Ugandan Shillings only.

5.23)  Policy Disputes:

The parties to this Policy expressly agree that the laws of the Republic of Uganda shall govern the validity, construction, interpretation, and effect of this Policy. Any dispute concerning the interpretation of the terms and conditions, limitations, and/or exclusions contained herein is understood and agreed to by both the Insured and the Company to be subject to Ugandan law. All matters arising hereunder shall be determined in accordance with the law and practice of such court within Ugandan Territory.

5.24)  Arbitration:

If any dispute or difference shall arise as to the quantum to be paid under this Policy (liability being otherwise admitted) such difference shall independently of all other questions be referred to the decision of a sole arbitrator to be appointed in writing by the parties to the dispute/difference, or if they cannot agree upon a single arbitrator within 30 days of any party invoking arbitration, the same shall be referred to a panel of 3 arbitrators, comprising of 2 arbitrators – 1 to be appointed by each of the parties to the dispute/difference and the third arbitrator to be appointed by such 2 arbitrators. The arbitration shall be conducted under and in accordance with the provisions of the Arbitration and Conciliation Act 2000.

It is hereby agreed and understood that no dispute or difference shall be referred to arbitration, as hereinbefore provided if the Company has disputed or not accepted liability under or in respect of this Policy.

It is expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon this Policy that the award by such arbitrator/arbitrators of the amount of the loss shall be first obtained.

5.25)  Terms of renewal:
  • The Company offers life-long renewal unless the Insured/ Insured Person or anyone acting on behalf of an Insured/ Insured Person has acted in an improper, dishonest or fraudulent manner or has made misrepresentation in relation to this Policy or the Policy poses a moral hazard.
  • The premium for renewal will be applicable as per the premium chart based on age; Sum Insured;
  • The company will not load the premium for any adverse claims experience of a particular Insured/Insured Person at the time of renewal if there is no change in the coverage of continuing
  • The Company may change the renewal premium and/or benefits payable subject to approval from the regulator (IRA) and inform the same to the Insured at least 3 months prior to the effective date of revision and/ or modification or
  • In the likelihood of this Policy being withdrawn in the future, the Company will inform the same to the Insured at least 3 months prior to expiry of the Policy. Insured will have the option to migrate to other plans under a similar health insurance Policy at the time of renewal, provided the Policy is maintained without a

All applications for renewal of the Policy must be received by us before the expiry of the current Policy.  A Grace Period of 3 days for renewing the Policy is provided under this Policy.

However, there is no coverage for Injury sustained or Disease contracted during this grace period/break period.

5.26)  Sum Insured Enhancement:
  1. The Insured member can apply for enhancement of Sum Insured at the time of renewal by submitting a duly filled fresh Proposal Form to the
  2. The acceptance of enhancement of Sum Insured would be at the discretion of the Company, based on the health condition of the Insured members, claim history, and subject to acceptance by the Company post

All waiting periods as defined in the Policy shall apply afresh for this enhanced Sum Insured from the effective date of enhancement of such Sum Insured considering such Policy Period as the first Policy in respect of such increased Sum Insured.

5.27)  Inclusion of Dependent members under the Policy:

New Person can be added to this Policy, either by way of endorsement in case of mid-term inclusion or at the time of renewal. Mid-term inclusion is available only in case of such new person i.e. spouse and or newborn child post 90 days of birth subject to acceptance by underwriters.

The pre-existing Disease clause, exclusions, and waiting periods will be applicable afresh in respect of such newly added person,

5.28)  Renewal Notice:

The Company shall allow the renewal of the Policy and accept renewal premium in all cases except in case of noncooperation of the Insured/Insured Person in implementing the terms and conditions of this Policy. Every renewal premium (which shall be paid and accepted in respect of this Policy) shall be so paid and accepted upon the distinct understanding that, no alteration has taken place in the facts contained in the original proposal or declaration hereinbefore mentioned and that nothing is known to the Insured that may result to enhance the risk of the Company. However, sending the renewal notice is not mandatory for the company.

5.29)  Notices:

Any notice, direction or instruction given under this Policy shall be in writing and delivered via email, SMS, by hand, post or facsimile to

  1. In case of the Insured, at the address given in the Schedule to the
  2. In case of the Company, to the Policy issuing office/nearest office of the
SECTION 6 – CUSTOMER COMPLAINTS PROCEDURE:

The Company is committed to extending the best possible services to its customers. However, If Policyholder/Insured Person have a grievance that he/she wish us to redress, he/she may contact the Company with the details of their grievance via:

Policyholder/Insured/ Insured Person may also approach the grievance cell at any of the company’s branches with the details of the grievance during working hours from Monday to Friday.

Escalation Level 1

In case the Policyholder/Insured/Insured Person has not got his/her grievances redressed through one of the above methods (After 5 days of intimating of your complaint), Policyholder/ Insured/ Insured Person may contact the Customer Success Adviser at:

Write to: Insure Small Small, Suzie House, Gaba Road, 1st floor, Suite 2

Call: 0700339931

Email: [email protected]

Escalation Level 2

In case the Policyholder/ Insured/Insured Person has not got his/her grievances redressed through any of the above methods (After 5 days of approaching Customer Success Adviser), Policyholder/ Insured/ Insured Person may contact the Customer Success Adviser at:

Email : customer@insuresmallsmall.com

Consumer Complaints Bureau of IRA

The insurance company should resolve the complaint within a reasonable time. In case if it is not resolved within 15 days or if the Insured/Insured Person is unhappy with their resolution you can approach the Consumer Complaints Bureau of IRA.

SECTION 7: CLAIM SERVICING:
7.1  Claim Notification – Multi-Model Intimation:

It is the endeavor of the Company to give multiple options to the Insured Person/Insured Person’s representative to intimate the claim to the Company. The intimation can be given in the following ways:

  • Call Centre of the Insurance Company (working hours) – 070-00339931
  • Login to the website of the Insurance Company and intimate the claim – http://www.insuresmallsmall.com/contact-us
  • Send an email to the Company – [email protected]
  • Post/courier to TPA/Company – Claims, Insure Small Small, Suzie House Gaba Road, 1st flr, Suite 2
  • Directly contact our Company office but in writing via email. – Insure Small Small, 1st Floor, Suzie House, Gaba Road, Nsambya next to the American Embassy

In all the above, the intimations are directed to a central team for prompt and immediate action.

7.2  Information Details

When the Insured/covered person/patient’s caretaker intimates the claim as mentioned above the following information should be given for prompt services.

  • Policy number
  • Name of the Insured
  • Name of Covered person/Insured member making the claim
  • Contact details
  • Nature of the Disease, Illness, or Injury
  • Name and address, phone number of the attending medical practitioner/hospital.
  • Date of hospitalization
  • The Notification of   Claim should be ideally provided by the Insured/Insured Person. In the event Insured / Insured Person is unwell, then the Notification of Claim should be provided by any immediate adult member of the
7.3  Claim Form

Upon the notification of the claim, the TPA/Company will dispatch the claim form to the Insured/Covered person. Claim forms will also be available with the network hospitals and Company offices and on its website, via USSD, WhatsApp or SMS.

7.4  Claim Procedure
  • Cashless Treatment:
  • The insured/Covered person shall use their mobile device to file a Notice of Claim
  • The company will generate a unique Claims Token with an expiry period
  • The insured/Covered person shall use that Claims Token for a cashless treatment.
  • The company will work with one or more TPAs for providing a cashless facility to the Insured/Covered
  • A list of network pharmacies will be available on the website of the TPA/Company
  • Denial of the cashless may not necessarily mean the claim has been rejected. Such claims may be examined on merits and will be paid on a reimbursement basis later if
  • The cashless pharmacy shall send the requisite claim documents to the TPA/Company seeking
7.4.2  Reimbursement Claims
  • All reimbursement claims should be intimated to TPA/Insurance Company within 7 days from the date of
  • Insured/covered person admitted in a non-network hospital can send the claim documents to the TPA/Company for reimbursement within 30 days from the date.
7.5  Claim Service Guarantee
  • Reimbursement Claims

Notwithstanding the above, upon the receipt of all required documents and processing of the claim, the offer of settlement will be made to the Insured in any case not later than 15 days’ maximum. Settlement (payment) of claim will be made within 7 days of receipt of acceptance in response to offer of settlement, failing which penal interest (in compliance with applicable regulations) at a rate of    2% higher than bank rate (prevailing as on the date of the beginning of financial Month in which the claim is reviewed) will be paid.

7.5.2       Cashless Claim:

In the event of delay in the approval of the cashless claim, a penalty of 50/- for every delay of 72 hours beyond 72 hours in case of emergency hospitalization and 72 hours in case of planned hospitalization after/of receipt of all information/documents subject to a maximum of 500/- will be paid by the Company.

Checklist of documents for settling Claims

SL. NO

CHECKLIST

TICK THE BOXES

1

Claim Token

2

Claims Form

3

Laboratory Test

4

Doctor/Medical Practitioners prescription

5

Pharmacy Bill

  • Documents

It is the policy of the Company to seek documents in a single shot/request. Based on documents submitted, if any further documentation is required then it will be sought promptly, at the earliest.

In cases where an investigation is deemed necessary, the same will be conducted in all promptitude. Every attempt will be made to keep the process transparent.

Repudiations

The power to repudiate claims is vested in the corporate office to ensure transparency.