Last Updated on: Monday, 08 Apr 2024

1) What is An Application Form? When is it required?

An Application Form is the basic enrollment form for the health coverage. It is also used to add additional dependents under the Policy.

2) What is a Pre-authorization Form? When is it needed?

In case of a hospitalization, Pre-authorization Form is the Company’s standard Form used to obtain Credit Facility at Network Hospital.

3) What is a Claim Form? When is it needed?

A Claim Form is the Company’s standard Form required for filing a Claim for re-imbursement when the treatment is obtained without the credit facility and you have settled the hospital bill out of pocket.

4) What are the Eligibility Terms for this product?

	Eligible Relations:	Self and Dependents (Spouse, Children & Parents)
	Admissible Ages:	Up to Sixty (60) years at the time of enrolment

Children should be at least three (03) months old

Once enrolled, the coverage can be continued up to the age of 65 years.

5) When will my coverage start?

Your coverage will start Fifteen (15) days from the date EFU Life receives the completely filled Application Form along with the premium payment. The Coverage Effective Date is mentioned in your Policy Document and Health Card.

6) Can I include any of my dependents if currently I do not have any?

They can be included in the policy, if eligible, within 30 days of them becoming eligible. All new dependants must be enrolled by completing the Application Form.

7) What if my health expenditure is more than my available limit?

Can I claim the remaining amount next year? Your Annual Limit is the maximum amount you can claim during a single policy period. In case, the actual expenditure exceeds the available limit, the excess amount will have to be borne by the Insured Members themselves.

8) What is No Claim Bonus / Bonus Limit?

In case of NO Claim on your Policy for any two consecutive Policy Years, the Company will give a No Claim Bonus in the form of a Bonus Limit. The Bonus Limit will be equal to 10% of the Basic Annual Limit and it will function in the same way as your Basic Annual Limit. A person can qualify for a No Claim Bonus until the Age of 54 years.

9) What is High Claim Loading?

In case of high claim on your policy during the immediately preceding three policy years (preceding one or two policy years for first two renewals), the Company may increase the Renewal Premium at the following rates.

	Claims up to 50% of Premium	No Extra
	Claims up to 75% of Premium	15%
	Claims up to 100% of Premium	20%
	Claims more than 100% of Premium	25%

In case of any increase in the basic premium rates (due to increase in age band or revision of premium rates), the loading will be applied on the revised premium.

10) How long can I stay covered?

The policy is issued for a period of one year and is renewable annually. The maximum enrollment age under this policy is sixty (60) years. Once enrolled in the policy the coverage can continue up to the age of sixty-five (65) years.

11) Can I enroll my new born baby during a policy year?

Yes, you can enroll your new born baby within thirty (30) days of his becoming eligible for insurance.

12) After how many days the coverage of my new born baby will start after enrollment?

The coverage of your new born baby will start immediately from the date of enrollment.

13) What if I was unable to enroll my new born baby within thirty (30) days of eligibility?

Enrollment of new born baby will not be accepted after thirty (30) days of the date of eligibility. In case you don’t apply for his insurance within thirty (30) days of eligibility, you may still get him enrolled under your policy from the next renewal date.

14) I am already covered under my Company’s group health policy. Can I still buy Individual Health Policy?

Yes, you can still buy Individual Health Policy to augment your group health coverage. Your Company’s group health policy’s limits may not be enough to cover your medical expenses. In case a claim is not payable under your group contract due to a lower limit, you can apply for its reimbursement under the individual policy.

Secondly, your company may not be covering your dependants. You can also buy health policy for them so that your whole family can enjoy a peace of mind.

15) Can I claim my medical expenses both from my Individual Policy and My Company’s group health policy?

You can claim your medical expenses under any of the two policies. In case the claim is not fully reimbursed under the first policy, due to shortfall of your annual limit, you can claim the remaining amount from the other policy. Please note that you can not claim more than you spend on the treatment under these policies.

16) What is the purpose of the Health Card?

Your Health Card contains the basic information about your coverage. You will need to show your Health Card each time you seek Treatment at a Network Hospital. It identifies you to the Network Hospitals and supplies them with key information about your Coverage. While making telephone enquiries with us we will also ask for the information on Health Card to identify you.

17) What should I do if I misplace or damage my Health Card?

If you misplace or damage your Health Card, you must report this to Individual Health Department immediately so that a duplicate Health Card can be issued after due verification.

18) What is a Network Hospital?

Network Hospitals have been selected by our team of doctors after due evaluation of the available services, staff and faculty doctors at these hospitals. Company has a credit arrangement with all its Network Hospitals.

What are the advantages of a Network Hospital?

In case you need to be hospitalized, you can select any of the Network Hospitals to obtain quality medical care without having to pay out of your pocket.

You can avail the credit facility arranged by EFU Life through a simple Pre-authorization procedure and EFU Life will settle your bills directly to the hospitals, as per your entitlement. This relieves you from the financial distress and you can concentrate on the recovery process.

19) Whom do I contact if I have a problem with a Network Hospital?

In case you have a problem with any of the Network hospitals, please do not hesitate to immediately contact our 24hours Medical Hotline which is managed by our staff doctors for your assistance.

20) What is Credit Facility / Pre-authorization?

Credit Facility means that when you go to a Network Hospital for a covered in-patient treatment you are not required to pay to the hospital. You can receive the covered Medical Treatment on credit at a Network Hospital and EFU Life will directly settle the bill to the Network Hospital on your behalf.

In order to avail the credit facility, you need to get a Pre-authorization from EFU Life so that it can arrange the credit facility after evaluating your case in line with the terms of the policy. The process is as follows:

When seeking Inpatient Treatment, a Day Care procedure or any of the three specialized investigations (MRI, CT Scan, and Thallium Scan) you should fill in the Pre-Authorization Form available at the admission office of all Network Hospitals and send it to us three days in advance of the Treatment. The form should also be signed by your Treating Physician. We will evaluate your form in light of your policy’s terms of coverage and confirm approval of the credit facility through phone/fax/email/letter. We will also inform the Network Hospital about the credit facility. On the day of admission you can simply go to the Network Hospital, show your Health Card at the admission office and obtain the necessary medical Treatment without having to pay out of pocket. You may however, be asked to pay for your personal convenience items like phone calls, attendant’s meal, tissue paper etc. Some Hospitals might also ask you to make a small initial deposit which will be refundable at the time of discharge after deducting your personal convenience items (phone calls, attendant’s meal, tissue paper box etc.)

21) If the Credit Facility is denied by EFU Life, does this mean my claim is not payable?

Not necessarily! Sometimes, there may be an ambiguity in the patient’s history and it may not be feasible to readily confirm the coverage of Treatment under the policy. In this case, the patient will be informed to make the payment to the Network Hospital and claim reimbursement later on. Please obtain all receipts, reports, attending physician’s statement and discharge note from the Hospital and submit to us along with our Claim Form for evaluation. In case it is found that the Treatment falls with in the policy, the claim will be processed within fifteen (15) days.

• Can I obtain treatment at Non-Network Hospital?

  Yes! But the treatment expenses will have to be initially borne by you. EFU Life will reimburse these expenses on submission of the bills, subject to the reasonable & customary charges that would have been incurred at a comparable Network Hospital for similar treatment. For this reason and also because Network Hospitals are generally better than the Non-Network Hospitals in terms of quality of care, we strongly recommend to use a Network Hospital.

• Are Pre-existing Conditions covered?

  “Pre-Existing Medical Condition” under this Health Insurance Policy shall mean any sickness, illness, disease, injury, symptom, co-morbid condition or the underlying cause, condition, sickness, illness, disease, injury or risk factors of an illness or any disease that causes another illness due to direct or indirect impact, has been known, was treated, is under treatment, any treatment required or has been investigated even if no medical advice or diagnosis or treatment was sought, prior to applying for health insurance.

  Usually, pre-existing conditions are not covered under these types of insurance products. However, TAHAFFUZ will provide coverage for treatment related to pre-existing medical conditions after four (04) policy years. This is one of the unique advantages of this product.

22) Am I covered for my health expenses incurred outside Pakistan?

Yes! Provided the following conditions are met:

• the Insured Member did not travel for the sole purpose of getting this treatment
• the expenses are incurred on ‘emergency’ and ‘medically necessary’ treatment
• the insured member did travel for the purpose of getting a medical treatment but only because such treatment was not available within Pakistan at any network or non-network hospital
• the Treatment is otherwise covered under the policy and does not fall in any of the exclusions
• the Insured Member has cleared the bills of the hospital abroad and then applied to EFU Life for reimbursement

In all cases, the claim will be reimbursed subject to availability of Annual Limit of the Insured Member and not more than what such Treatment would have cost in Pakistan at a Network Hospital that the Insured Member was otherwise entitled for.

23) Can I ask for change in my benefit plan during the policy period?

You can not request for change in your benefit plan during the policy period. However, the same can be requested at the time of renewal of the policy. The Company reserves the right to deny such request or to accept them subject to some special conditions.

24) Are there any Exclusions?

Expenses arising from or related to Pre-existing conditions (during the first 4 years), Pregnancy and Childbirth, Outpatient treatment, Congenital Birth Defects, War, Invasion, Civil unrest, Infertility, Cosmetic treatment, routine Medical Checkups etc. are not covered.