Terms of Use

Membership

A member must have completed a registration form, agreed to the terms and conditions herein and paid appropriate premiums. The member must ensure that no false or fraudulent information, misrepresentation or incomplete information is provided on the registration form. In the event that the information provided by the member is found to be false, fraudulent, incomplete, or a misrepresentation; the member may face action including, but not limited to suspension or loss of membership and or criminal charges.

Eligibility for membership under the scheme will not be affected by race, color, or national origin. Depending on the requirements for membership registration, age, sex, state of health, disability or citizenship status may be a factor in whether or not an applicant will be eligible for membership. The scheme will provide the member with an ID card, list of benefits and exclusions and list of providers.

 

Premium

Premiums payable for the health plan to the scheme will be made in Ghana cedis in accordance with a payment schedule agreed upon by the scheme and the member. The scheme is not liable to pay for any medical services that arises as a result of illness or injury be it fortuitous or not, of the prospective member during the waiting period.

 

Waiting Period

Commencement of cover is subject to a waiting period of thirty (30) days from the day after the premium is paid in accordance with the schedule agreed upon by the scheme and the member. In the event of an error or delay in registration, the scheme will not reimburse the member for any medical expenses whether the provider is contracted by the scheme or not.

 

Benefits And Exclusions

The member is eligible for medical benefits available under the health plan for a period of one year only from contracted providers. The scheme is not liable to pay for any medical services that are not covered under the health plan and/or medical services stipulated in the exclusions list of the policy.

 

Renewal

The policy cover will run for one year, after which the member will be required to renew the policy to receive cover for the subsequent year. The scheme will send a renewal notice to the member which would show the premium due and the due date in accordance with the premium payment schedule agreed upon by the scheme and the member. The policy will lapse if premium payments are not made within five (5) working days after the due date.

 

Limits

Each member is entitled to outpatient and day patient services of up to GH¢ 3,000, which includes all prescribed investigations and medications as well as general medical emergencies under the health plan. The members are also entitled to inpatient services of up to GH¢ 25,000 which includes accommodation, prescribed investigation, prescribed medication and general medical emergencies.

 

Claims Management

The member shall be required to prove his/her eligibility for benefits by submitting the ID card to the provider. The provider shall require the member to validate his/her membership after which medical services may be provided to the member if he/she is eligible for benefits under the health plan. The scheme shall pay all legitimate claims on behalf of the members to the providers after providing services to the members according to the benefits in the health plan and on no account shall direct payment be made to the members in accordance to NATIONAL HEALTH INSURANCE REGULATIONS, 2004 (LI 1809).

 

Dependents

In the event that the health plan covers the member and his/her dependent(s), the dependent(s) shall receive benefits under the health plan selected for the dependent(s). The terms and conditions stated under the health plan selected for the dependent(s) apply to the dependent(s).

 

Limits

The member shall use the ID card given by the scheme as the membership authentication device at the provider sites and under no circumstance shall the member consent to another person, member or non-member, accessing medical service with the ID card given to the member unless that person is a dependent of a member.

The member shall not use the benefits under the scheme to cause harm to the health or safety of the member.

The member commits an offence and is liable to legal action if the member defrauds or attempt to defraud the scheme by conniving with a provider or other person to make a claim for, including but not limited to the following

  1. A service which has not been provided.
  2. A service which the member does not need but which the provider purports
  3. to have provided.
  4. A medicine prescription which the member does not require or which is more than the member requires.
  5. A service which was received by hiding the truth from the provider and indulge in any other fraudulent or dishonest acts in respect of the scheme. The member may be suspended or the policy terminated if the suspicion of fraud or attempt to defraud the scheme is confirmed.

In the event of termination of membership, the member must return the ID card as it is the property of the scheme.

 

Cancellation

The member may cancel the policy at any time by giving notice to the scheme thirty (30) days to the date of cancellation. The member has a ‘cooling off’ period of fourteen (14) days from when he receives a cancellation form from the scheme. During the ‘cooling off’ period the member can exercise his right by completing and signing a cancellation form from the scheme. In the event of cancellation of membership, the member must return the ID card as it is the property of the scheme. Penalty charges shall apply in the event of cancellation of membership. The penalty charge shall be a pro-rata return of premium (provided the member has not made a claim during the current period of insurance and will be calculated taking into account the number of days remaining on cover) less investment management expenses, processing fees and taxes.

 

Death of a Member

In the event that the member dies, the policy shall be cancelled and a pro-rata return of premium less investment management expenses, processing fees and taxes be paid to his/her next of kin as stated in the registration form. If the member’s health plan covers his/her dependent(s), the policy will run until the end of cover.

 

Amendment

It is the responsibility of the member to notify the scheme of any changes in the information provided in the registration form including, but not limited to, change of name, gender, address due to residential move and any other information that affects his/her membership. Any such notification will be effective only when received by the scheme.

 

Reviews

The member has the right to cancel this policy within the waiting period and receive all premiums paid less the cost of any benefit, if he/she is not satisfied with the terms and conditions provided by the scheme. This cancellation must be made in writing by the member and delivered to the scheme’s physical address.

 

Other Insurances

Claims resulting from an accident or work-related illness/injury that are covered by any other insurance policy e.g. motor insurance, workmen compensation, life insurance, liability insurances etc. would not be paid by the scheme. Also in filing a claim or lawsuit against a third party to recover the costs incurred as a result of an accident or work-related illness/injury paid by the scheme, the member shall inform the scheme of such developments.

 

Communication

The member may only regard communication with the scheme as received if sent by registered post or acknowledged in writing by the scheme.

 

Confidentiality

The scheme acknowledges that information, which has or will come into the possession or knowledge of the scheme in connection with this policy include confidential and proprietary data whose disclosure to or use by third data would be damaging. The scheme shall maintain all information developed by the scheme in the terms of this policy including, but not limited to, personal and medical information, applicable to or arising out of the implementation of this policy in strictest confidence. The scheme shall not disclose any prospective or existing member’s data or medical records which it has or will come into possession or knowledge of in relation to any prospective or existing member except that it may use such information in appropriate circumstances for administrative purposes in terms of this policy, provided, however, that the scheme has the right to such data and is in compliance with the law, the rules and any existing and applicable privacy law.

 

ADDRESS

  • Address: CDH HOUSE, 36 Independence Avenue,
    P.O. Box 14911, Accra, Ghana.
  • Email: support@phoenixhealth.com
  • Website: www.phoenixhealth.com
  • Telephone: (+233-302) 671050; 667426; 668463; 7010394

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