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Re- launch Hospital Cash Plan Insurance Benefit (HCP) Processes and Procedures . Areas to cover. HCP Definitions. HCP Benefits. HCP Terms and conditions. HCP Interpretations HCP Registration. HCP cancellation. Edgars Club Subscription/Premiums Billing & payments. HCP claims process.

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re launch hospital cash plan insurance benefit hcp processes and procedures
Re- launch

Hospital Cash Plan Insurance Benefit (HCP) Processes and Procedures .

areas to cover
Areas to cover.
  • HCP Definitions.
  • HCP Benefits.
  • HCP Terms and conditions.
  • HCP Interpretations
  • HCP Registration.
  • HCP cancellation.
  • Edgars Club Subscription/Premiums Billing & payments.
  • HCP claims process.
  • FAQS.
definition edgars club hcp insurance plan
Definition Edgars Club (HCP) Insurance Plan
  • HCP is an insurance product is aimed at covering incidental expenses incurred during hospitalization which are normally not covered under Health/medical aid insurance
  • Health/Medical insurance reimburses inpatient hospital bills. Hospital cash plan offers you fixed daily benefits, after 48 hours spent in hospital. This Policy is classified as a Health Short-Term Insurance and should not be seen as a Medical Aid Scheme and does not provide cover equivalent to that of a Medical Aid Scheme.
  • Hospital cash plan is not a substitute for medical insurance, but a supplement to the existing health insurance covers bought individually or provided by the employer. While health insurance helps you take care of hospital & medical bills, there are several other expenses incurred during hospitalization such as charges for patient’s diet, patient’s attender’s lodging, money spent on commuting from home to hospital and back.
  • The HCP is a benefit offered for free to subscribing Edgars Club members.
  • Club Members can however add beneficiaries to their policy for a fee.
  • The HCP being an insurance product is underwritten by Eagle Insurance Company Limited.
edgars club hcp benefits
Edgars Club (HCP) Benefits

Edgars Stores Limitedwill pay the Insured Person the Benefits Listed below if during the Period of Insurance any Insured Person suffers Sickness or Bodily Injury which results in any Sick or Injured Person's Hospitalization, provided:

• Hospitalizationoccurs within 30 (thirty) days of any injury or sickness;

• The sickness or injury was suffered during the currency of the Policy;

• The sickness or injury falls within the policy terms and conditions included herein.

HOSPITAL CASH PLAN BENEFITS.

  • Cash pay-out of $100-00 each day spent in hospital when admitted for more than 48 hours
  • A maximum pay-out per claim is limited to $3 000-00 per event and $6 000-00 per year.
  • An Edgars Account debt relief or credit of $200 for hospitalizationof 7 days and above (only limited to the principal policy holder).
  • 100% debt relief of the whole amount outstanding if the principal account holder passes on.
edgars club hcp benefits cont
Edgars Club (HCP) Benefits Cont…
  • Unlike funeral policies, with Hospital Cash Plan you stand to benefit over and over again provided the limits are not exhausted.
  • Unlike funeral policies which never benefit the insured alive, Hospital Cash Plan benefits both the insured and relatives while they are still alive.
  • An immediate cover for accident caused admissions and 3 months waiting period for hospitalizationdue to illness and 6 months waiting period for planned surgeries.
  • Claims paid within 5 working days when all claim supporting documentation is submitted.

Also the Edgars Club Subscriber can add beneficiaries. The following conditions apply

  • Cash payout of $100-00 for an adult beneficiary and $50-00 for a child beneficiary for each day spent in hospital when admitted for more than 48 hours.
  • A maximum pay-out per claim of $3 000-00 for an adult beneficiary per event and $1 500-00 for a child beneficiary and $6 000-00 and $3 000-00 per year respectively.
  • An immediate cover for accident caused admissions and 3 months waiting period for hospitalizationdue to illness and 6 months waiting period for planned surgeries.
  • The benefits arising as a result of hospitalization of beneficiaries are paid to the Club member only.
edgars club hcp terms conditions
Edgars Club (HCP) - Terms & conditions
  • The Company will pay Daily Cash Benefits from the third consecutive day of hospitalizationdue to Sickness or Bodily Injury subject to the waiting periods outlined in this document. This means that no payment will be made in respect of the first or second day in hospital. Re-hospitalizationwithin 10 (ten) days for the same cause counts as the same event. The Benefit in respect of Children younger than 18 (eighteen) (Age Last Birthday) will be paid at 50% of the normal Daily Cash Benefit.
  • Hospital Cash Back Benefits will be payable for hospitalizationat any registered hospital in the Republic of Zimbabwe.
  • Reinstatement of a lapsed Policy may be effected by the Company at its own discretion and subject to such Terms and Conditions as the Company may require from time to time and to the recommencement of the full duration of any required Benefit limitation or waiting period(s).
  • The Policy may be cancelled at any time by the Policy Owner by giving one calendar month notice in writing. The Company may cancel this Policy by giving one calendar month notice in writing to the Insured Person’s last known address.
  • All Benefits under this Policy will be forfeited if a claim is fraudulent in any respect or intentionally exaggerated. The Company will cancel this Policy and all premiums paid hereunder will be forfeited.
edgars club hcp terms conditions cont
Edgars Club (HCP) -Terms & conditions Cont…
  • Written notice of a claim must be given to the Company as soon as possible but in any event within 30 (thirty) days of the date which may give rise to a claim. The Insured Person or Beneficiary shall supply in writing at his/her own cost any reasonable information that the Company may request.
  • The Company reserves the right to amend, add or change the Terms and/Conditions of this plan by giving one month’s written notice of its intention to do so. Any variations and or changes will be binding on both the Insurer and the insured and can be applied at any time to the existing Terms and Conditions after written communication of these changes has been sent to the Policy Owner’s last known address.
  • A full medical history may be requested at claims stage together with reports by the regular and attending doctors to validate any claim and the impact of any Pre-Existing Condition. A certified copy of the Insured Person’s identity document and a copy of the Hospital account (in order to confirm the number of days in Hospital) must be provided by the claimant. In order to qualify for the claim, all monthly Premiums must be paid on time. The Company reserves the right to call for any additional documentation as may be required from time-to-time to validate the information provided.
edgars club hcp terms conditions cont1
Edgars Club (HCP) - Terms & Conditions cont…
  • Written notice of a claim must be given to the Company as soon as possible but in any event within 30 (thirty) days of the date which may give rise to a claim. The Insured Person or Beneficiary shall supply in writing at his/her own cost any reasonable information that the Company may request.
  • The Company reserves the right to amend, add or change the Terms and/Conditions of this plan by giving one month’s written notice of its intention to do so. Any variations and or changes will be binding on both the Insurer and the insured and can be applied at any time to the existing Terms and Conditions after written communication of these changes has been sent to the Policy Owner’s last known address.
  • A full medical history may be requested at claims stage together with reports by the regular and attending doctors to validate any claim and the impact of any Pre-Existing Condition. A certified copy of the Insured Person’s identity document and a copy of the Hospital account (in order to confirm the number of days in Hospital) must be provided by the claimant. In order to qualify for the claim, all monthly Premiums must be paid on time. The Company reserves the right to call for any additional documentation as may be required from time-to-time to validate the information provided.
edgars club hcp terms conditions cont2
Edgars Club (HCP) - Terms & Conditions cont…
  • The Company will pay up to the limit corresponding with the Hospital stay, directly to the person who is to receive it (the Club Member) on proof of hospitalisation of a Life Insured as a result of an accident or illness, provided that such hospitalisation occurs during the currency of this Policy and outside any applicable waiting periods.
  • The Benefits together with the relevant waiting periods commence upon receipt of the first Premium
  • In the event of non-payment of 1 (one) month’s consecutive Premiums, the Policy will automatically lapse. If at the time of a claim your premiums were not paid then you will not stand to benefit from the payout. If also you skip monthly payments then you will have to start your 3 month waiting period again.
  • In the event of part payments of the premium the Company will only be liable to pay as compensation a ratable proportion which the paid premiums bears to the total premiums due
  • In the event of one policy holder having taken out several policies on their life , the Company will only pay compensation for benefits which accrue on one policy
  • The next of kInof the principal can claim on behalf of him/her that is if, he/she dies after being admitted in hospital. However he/she will be required to provide all the required documents to make a claim including the death certificate
edgars club hcp terms conditions cont3
Edgars Club (HCP) - Terms & Conditions cont…

GENERAL EXCLUSIONS:

  • The Company will not be liable in respect of any claim for Bodily injury, Sickness, or Accidental disability which is directly or indirectly caused by, arising from, contributed to by, aggravated by, connected with, or resulting from any of the following:
  • War, invasion by a foreign country, acts of foreign enemies, hostilities (whether war is declared or not), civil war, labour disturbances, active participation in strikes or the activities of locked-out workers, rebellion, revolution insurrection or military or usurped power, or the Insured Person engaging in military duty or military exercises with any armed force of any country or international authority will not be covered.
  • Intentionally self-inflicted injury or attempted suicide, while sane or insane, will not be covered.
  • Engaging in (or practicing for or taking part in training peculiar to) underwater activities necessitating the use of artificial breathing apparatus, climbing or mountaineering necessitating the use of ropes or guides, potholing, parachuting, hang-gliding, winter sports involving snow and ice, professional sports or racing other than on foot will not be covered.
edgars club hcp terms conditions cont4
Edgars Club (HCP) - Terms & Conditions cont…

GENERAL EXCLUSIONS:

  • Engaging in aviation other than as a fare-paying passenger in a fixed-wing aircraft provided and operated by an airline or air charter company, which is duly licensed for the regular transportation of fare-paying passengers or in a helicopter provided and operated by an airline which is duly licensed for the regular transportation of fare-paying passengers, provided such helicopter is operating only between established commercial airports and/or licensed commercial heliports will not be covered.
  • The actions of any Insured Person contrary to the law, criminal or otherwise, will not be covered.
  • The driving of a motor vehicle while the blood alcohol level of the insured Person is higher than that permitted by law, irrespective of whether such action causes an accident or not, will not be covered.
  • Illegal acts of the Insured Person(s) or the Insured Person(s)’ personal representatives will not be covered 
edgars club hcp terms conditions cont5
Edgars Club (HCP) - Terms & Conditions cont…
  • SPECIFIC EXCEPTIONS;
  • Confinement for routine physical or any other examination where there are no objective indications or impairment in normal health will not be covered.
  • The Insured Person having taken a drug unless it is proved that the drug was taken in accordance with proper medical prescription and not for the treatment of a drug addiction, will not be covered.
  • Any psychological or psychiatric disease or disorder, including Post Traumatic Stress Disorder will not be covered.
  • Confinement in an establishment which is not a Hospital as defined herein will not result in a valid claim and will not be covered.
  • Operations, treatments and examinations for obesity, cosmetic purposes or of the Insured Person’s own choosing which has no connection with any illness, will not be covered.
  • The treatment of infertility or the artificial insemination of a person as defined in medical terms will not be covered.
  • Hospitalisation or disability as a consequence of breast reduction and enlargement operations.
  • Dental conditions and treatment will not be covered.
edgars club hcp terms conditions cont6
Edgars Club (HCP) - Terms & Conditions cont…

SPECIFIC EXCEPTIONS;

  • Any hospitalisation not recommended by a qualified doctor will not be covered.
  • Any hospitalisation undertaken in nature, cure clinics, or hydros or during periods of quarantine will not be covered.
  • Cosmetic or Plastic surgery except in the case of bodily reconstruction after injury will not be covered.
  • Alcohol or drug dependence syndrome including treatment of any medical condition which, in the opinion of the Insurer’s consulting Physician, is considered to be either an underlying cause of, or directly attributable to, alcohol or drug dependence syndrome, will not be covered.
  • Hospitalisation for the investigation of pain or pain-related conditions and treatment in this context includes bed rest, traction, physiotherapy; spinal blocks, medication, or intravenous medication will not be covered.
  • Hospitalization for surgery within the first six months of payment of the first premium unless the surgery is a result of an accident.
  • Any hospitalization for the removal of cists and fibroids
  • Any persons below the age of three months or older than sixty four years
edgars club hcp interpretations cont
Edgars Club (HCP) – Interpretations Cont…

ACCIDENT

  • “Accident” means a sudden, uncertain, and unexpected event which is caused solely and directly by violent, external, physical, and visible means and independently of any other cause. Such accident must result in an external, visible injury confirmed by clinical examination and appropriate testing, and excludes the following:
  • Any event that is traceable to psychiatric trauma and the Insured Person’s state of mental or physical health prior to or after the event that gives rise to a claim;
  • Non visible soft tissue injuries excluding clinically confirmed ligament and tendon damage that requires surgical intervention.

CHILD

A child refers to a male or female dependant below the age of eighteen years.

DAY

This refers to a period of 24 (twenty-four) consecutive hours of hospitalization.LIMITATION OF STAY.

  • The Company reserves the right to limit any duration of hospitalisation if, in the opinion of our appointed Chief Medical Officer, the duration of admission is not justified.
edgars club hcp interpretations cont1
Edgars Club (HCP) – Interpretations Cont…

HOSPITAL

  • “Hospital” is defined as an institution which:
  • Is licensed in accordance with the applicable laws of the jurisdiction in which it is located;
  • Is primarily engaged in providing for compensation for its patients, diagnostic, medical, and surgical facilities for the care and treatment of injured or sick persons;
  • Has staff of one or more qualified Physicians available at all times;
  • Has 24 hour day nursing services by registered graduate nurses under the permanent supervision of the Physician in charge;
  • Maintains in-patient facilities;
  • Maintains a daily medical record for each of its patients;
  • Does not include any institution which is primarily a rest or convalescent facility, rehabilitation wards or centres, a place for custodial care, hospices, a facility for the aged or alcoholics or drug addicts or for the treatment of psychiatric or mental disorders, or a nursing home, even if it is registered as a Hospital or clinic.
edgars club hcp interpretations cont2
Edgars Club (HCP) – Interpretations cont….

ILLNESS

Means sickness or disease contracted and commencing during the currency of this Policy.

INSURED PERSON / LIFE INSURED

Means the person(s) who proposed or applied for The Club Membership and subsequently paid the membership subscription who is/are a resident(s) of the Republic of Zimbabwe, residing in Zimbabwe and in possession of a valid Zimbabwean identity document

PHYSICIAN

Means a medical practitioner duly qualified, registered, licensed and practicing within the scope of his/her license pursuant to the laws of the Republic of Zimbabwe. Physician shall not include the Insured Person whose Hospitalisation is the basis of a claim hereunder, or a relative by blood or marriage of such Insured Person unless approved by The Company.

edgars club hcp interpretations cont3
Edgars Club (HCP) – Interpretations Cont…

PRE-EXISTING MEDICAL CONDITION

  • Means sickness or bodily injury sustained or contracted by an Insured Person for which he or she has or should reasonably have received relevant medical treatment or advice by a Physician, prior to such Insured Person’s initial Commencement Date or Reinstatement Date of Insurance under this Policy, whichever is more recent. This includes, but is not limited to, any physical or mental defect, disease, infirmity, or condition which existed prior to the initial Commencement or Reinstatement Date of this Policy whichever is more recent.
  • The policy does not discriminate against any pre-existing medical conditions as long as the hospitalization occurs after the waiting period.

SPOUSE

Means the person married (whether by civil, customary, tribal or religious union) to the Insured. Cover is limited to one nominated spouse where a person has more than one.

WAITING PERIODS

  • No claims as a consequence of illness will be considered during the waiting period. Only claims as a direct consequence of an accident will be considered during the waiting period. Waiting periods will apply on the Policy: and for hospitalization due to Illness: The following waiting periods will apply on the Policy:
  • Hospitalization due to Illness: 3 (three) months after inception
  • Hospitalization for surgery: 6 (six) months after payment of the first subscriptionunless the surgery is a result of an accident.
edgars club hcp interpretations cont4
Edgars Club (HCP) – Interpretations Cont…

LIMITATION OF STAY.

  • The Company reserves the right to limit any duration of hospitalizationif, in the opinion of our appointed Chief Medical Officer, the duration of admission is not justified.
  • Hospitalizationfor treatment or control of chronic or acute pain (resulting from an illness or injury) will be limited to a maximum of 30 (thirty) days per event, paid from the third consecutive day of hospitalization, and a maximum of 60 (sixty) days allowed per policy per year. This means that no payment will be made in respect of the first or second day in hospital.

CLAIMS PROCEDURE

  • The policyholder has to submit the duly completed claim form with requisite documents normally within 10 days from the date of discharge to Edgars stores Limited. These documents include doctor’s report or hospital’s reference letter, discharge summary, diagnostic test reports, banking details, medical aid card and copies of cash invoice, if the patient paid cash. The claim forms will be processed within 1 week if all documents are attached and submitted within 10 days after discharge.
edgars club hcp registration
Edgars Club (HCP) – Registration

Registration on Edgars Club can be done using the following methods

  • A direct debit by Edgars on selected customer accounts.
  • By filling in a registration form

DIRECT DEBIT BY EDGARS.

  • Systems will, at the commencement of the Edgars Club i.e. end of March 2014 trading period, select certain customers based on the agreed account performance parameters and invite account holder to join the Club.
  • Systems will automatically debit these customers account with $3.
  • Customer will be give them an option to withdraw form Edgars club membership with three monthsand get refunded.
  • After three monthsthey become full members and if they decide to stop or withdraw from the club membership after three months, no refund will be given.
  • Systems will avail the list of selected club membership electronically to the CCS admin clerk administering the Hospital Cash Plan Edgars club benefit.
  • The admin clerk will upload the list on the HCP system for monitoring performance and record purposes.
  • The HCP admin clerk will forward the list the Eagle Insurance Company who are our underwriters.
  • Eagle insurance will acknowledge receipt and confirm number count.
  • Our customers become covered under the HCP insurance immediately on confirmation of receipt of the list by Eagle Insurance Company limited.
edgars club hcp registration1
Edgars Club (HCP) – Registration
  • 2.0 BY FILLING IN A REGISTRATION FORM.
  • An Edgars Club form will be available in-store.
  • The customer will complete the form and stores will send all the forms to the HCP administration clerk (CCS admin Clerk).
  • The clerk will compile a list of all new Club members
edgars club hcp cancellation of subscription
Edgars Club (HCP) – Cancellation of subscription

Cancellation

  • Should a customer selected to be an Edgars Club member wish to opt out of The Club, they can sms “OUT” and their 10 digit account number to 0782780780 within 3 months OR complete an “Opt Out” form in-store.
  • The Opt Out forms and OUT message must be routed to the HCP admin Clerk who in turn must hand over the information to the section manager to do the cancellation as the admin clerk has no access to the policy cancelation option.
  • After effecting the cancelation the section manager should notify Eagle Insurance in writing of all policy cancelation and Eagle insurance should acknowledge receipt of cancelled policies..
edgars club hcp billing payment of subscription
Edgars Club (HCP) – Billing & Payment of subscription

Billing of subscriptions.

Club subscriptions as well as HCP beneficiary fees are billed at the beginning of each trading month and they become due and payable at the end of the same trading month.

The subscriptions and the beneficiary fees are added to the monthly instalment together with funeral Insurance for those that have insurance.

Payments of subscription fee and beneficiary premiums.

These are paid in full at the close of trading period being an additional $3 plus any beneficiary premiums on the customer’s normal instalment. The order in which payments are deducted per month are funeral Insurance (for those covered), the Edgars Club subscription and instalment including LPC andinterest (if applicable).

Failure to pay Subscription fees.

  • Failure to pay subscription will result in a cancellation of the Club membership and all its benefits i.e. HCP, The Club Magazine, etc. No refund will be made.
  • At the end of each month systems will run a report for all those members who are up to date with their payments and those who are not.
  • All members who are not up-to-date will have their membership lapsing. Members with lapsing membership will be notified that their Club membership has lapsed and that they are no longer covered by our HCP insurance and cannot access any other membership benefit. They will be advised to re-join the Edgars Club if they so wish.
  • All lapsed membership will be cancelled and the cancellation procedure is as stated above . Eagle insurance must be notified in writing and also acknowledge receipt in writing.
edgars club hcp claims processing
Edgars Club (HCP) – Claims Processing

CLAIMS NOTIFICATION.

The following are legally accepted ways of notifying claims. When a claim is notified through any of the following methods, take the necessary steps to gather and verify information.

Telephone Call

  • Verify if the client has policy with the Edgars or not.
  • Client to complete a claim form with the help of stores staff clerk.
  • The form must be officially stamped.

Letter, fax, Email from Insured.

  • Verify whether the client is insured or not.
  • Have the letter, fax or email stamped.
  • When any of the above methods has been used, proceed to request for the relevant claim documents.
edgars club hcp claims processing1
Edgars Club (HCP) – Claims Processing

Documents Required.

  • Claim form (provided for at stores and on the website)
  • Doctor’s confirmation of stay in Hospital
  • ID which includes passport, driver’s licence, normal ID, birth certificate for children.
  • Confirmation of medical aid, if applicable. Copy of medical aid card will suffice.

Claims Registration

  • Avoid duplication. Check that the claim is not already registered.
  • Quantify loss amount. Calculate the number of days member stayed in hospital taking into account the 48 hours excess period. Calculation should be in terms of hours
  • Register the claim.
  • If claim is not valid immediately advise client and the reasons thereof. Be guided by the policy wording.

Claims Maintenance.

  • Follow up on outstanding documentation
  • Make follow ups on the documentation requested but not yet received
  • Diarise for any outstanding documentation.
  • Verify the legitimacy of the doctor by checking on the AHFoz list of registered doctors or any doctor’s association if in doubt with submitted documents.
edgars club hcp claims processing2
Edgars Club (HCP) – Claims Processing

CLAIMS REPUDIATIONS AND EX-GRATIA PAYMENTS

Claims repudiation should be done when

  • Claims contravenes policy terms and conditions
  • Claim is an excluded peril
  • Claim is fraudulent
  • Claim is contrary to public policy
  • Non-payment of premium

Ex-gratia requests

Write to the Section manager stating clearly why ex-gratia should be granted

Conditions for ex-gratia justification

  • Where there is genuine oversight
  • Borderline cases
  • To preserve business relations.

After the all documents have been collected and the claims documents completed, these will be sent to Eagles Insurance Claims department. It is Eagles Insurance Company Limited’s claim department who will give the final word as to whether Edgars must pay or not pay the claim.

edgars club hcp claims payments
Edgars Club (HCP) – Claims Payments
  •  Eagle Insurance will confirm in writing whether or not the claim will be paid or not.
  • On receipt of confirmation of payment or no payment from Eagle Insurance the section manager will notify the customer of the claim outcome.
  • If the claim has been accepted payments requisition will be prepared as normal and payment will be done to the customer.
  • The admin clerk should prepare a report of all claims paid and rejected one at monthend.
  • At month-end premiums paid to Eagle should net off against claims paid.
edgars club hcp frequently asked questions
Edgars Club (HCP) – Frequently Asked Questions

Q1. Can I be covered if I have any of the following conditions, HIV, Diabetes, Hypertension, Kidney problems, cancer, Asthma?

  • Yes as long as you have completed the waiting period of 3 months.

Q2. Are medicals required before I join?

  • No

Q3. Can I be covered if I am on a work permit and I am not Zimbabwean?

  • Yes, no documentation required same terms applicable to Zimbabwe will also apply.

Q4. Can I still claim if I am hospitalised outside of Zimbabwe?

  • Not at the present moment.

Q5. How long does a claim take to settle?

  • If all documents are in order within 5 days.

Q6. Are there any documents required for payment to be settled?

  • Admission and discharge proof, copy medical or proof of payment.

Q7. Is there a maximum number of dependents?

  • No

Q8. Is there an age limit?

  • 1 month to 65 years
edgars club hcp frequently asked questions1
Edgars Club (HCP) – Frequently Asked Questions

Q9.What happens when I reach that age after I have been contributing?

  • A new product for those above 65 is being worked upon.

Q10.What if my injuries are internal?

  • If it is a result of an accident it is covered.

Q11. What if I am being monitored and I stay in hospital for 3 days? i.e. my condition is being assessed either illness or accident?

  • Generally illness monitoring will not exceed the 2 days therefore you will be covered normally. Accidents will be covered within the product parameters.

Q12.What happens when the principal member dies?

  • Dependents can continue to pay to keep membership there is no pay-out benefit for the member.

Q13. What if a patient dies whilst they are hospitalised?

  • Payment in excess of the two day stay will be paid to the legal next of kin. Wheredisputesarisethemoneywillbeputinestate.

Q14. If I pay annually, do I still have to adhere to the waiting period?

  • Yes.

Q15. If I have an instalment shortfall and I am hospitalised do I get anything?

  • Yes but it is calculated prorate to your contribution.e.g. 50% of payment = 50% of benefit.

Q16. Does it lapse?

  • Yes if your instalment is not up to date. But you can be reinstated with the same waiting period.