What is covered under my plan?

Your Generali Worldwide Health Plan provides cover for medical services, hospitalisations and other benefits (i.e. additional vision, dental and/or life benefits) as elected by your company. Below you will find a high level summary of what is covered under our plans. Please refer to the Benefit Grid specific to your group to see what benefits apply to you locally, regionally and/or globally, or consult your Human Resources representative for further information on the terms and limitations of your plan.

• Comprehensive health cover including Medical, Dental, Vision, Life
• Insurance & Accidental Death & Dismemberment (please consult your benefits grid to confirm if your plan includes Dental, Vision, Life and/or AD&D)
  Access to local, regional and global health care (depending upon the plan elected)
• Extensive Global Provider Network: over 550,000 US doctors & hospitals and more than 2,000,000 doctor / hospital / facility relationships worldwide
• Access to the Generali Advantage Network - a specialty sub-network of key doctors & hospitals where Generali Worldwide has negotiated additional discounts that will save you money. Hospitals include leading medical centres, as well as facilities specialising in Cardiac and Cancer Treatment and Transplant services
• 24 hour emergency evacuation support services
• Dedicated local service through Generali Worldwide at Cayman Insurance Centre, George Town, Cayman Islands
• Dedicated global service through Generali Worldwide's Global Service Centre, Toronto, Ontario
• Medical case management
• Medical Director on staff - experienced in destination medicine, emergency trauma and flight physician
• Prescription drug cover worldwide
• Wellness services including routine physicals, well-child care and immunisations
• Workplace wellness program and healthchecks
• Cover for routine and medically necessary doctor office visits
• Comprehensive cover for inpatient and outpatient care
• Maternity benefits: prenatal care, delivery and newborn care
• Mental health services
  
  
  

What are my potential costs each year?

To determine your potential healthcare costs each year, you need to consider several variables, including your health insurance monthly premium, your deductible, co-insurance and other costs such as 'co-pays' and non-eligible expenses (expenses not covered under your benefits plan).

You can calculate your potential out-of-pocket costs by completing this simple equation:
Monthly Premium + Deductible + Co-insurance + Other costs (co-pay amounts, non-eligible expenses, etc) = Maximum Potential Annual Costs

How do I submit a claim?

The following procedures will help you prepare and submit claims. Final payment for any claim is based on many factors, including eligibility and applicable exclusions and other benefit limits. Please note: following correct claim submission procedures does not necessarily guarantee payment or reimbursement for any claim.

How do I submit a medical claim?
1) Complete a separate, signed claim form for each family member for each benefit claimed. On the claim form, complete the following questions:

- Number 1 (Patient's Name)
- Number 1a (Insured's ID Number)
- Number 12 (Patient's or Authorised Person's Signature).

2) Attach your original, fully itemised receipts / bills / invoices.

3) Submit the completed claim form, along with the original, itemised receipts / bills / invoices to Generali Worldwide for claim processing by either: (a) mailing the documents to the address on the back of your ID Member card; or (b) delivering or mailing the documents to Generali Worldwide at Cayman Insurance Centre in George Town, Grand Cayman.

Please keep copies of all completed claim forms and accompanying receipts for your own records.

Is there any additional information required for medical claims?

Original receipts / bills / invoices should include the Patient's name, Provider's name/address/telephone number, date of service, amount charged, diagnosis/nature of illness and procedures performed (office visit, lab, surgery, etc.). If the diagnosis/nature of illness is not shown, you may handwrite it on the bill / receipt and sign it.

How do I submit a dental claim?
1) Complete a separate, signed claim form for each family member for each benefit claimed. On the claim form, complete the following questions:
- Number 1 (Patient's name)
- Number 1a (Insured's ID number)
- Number 12 (Patient's or Authorised Person's Signature).

2) Attach your original, fully itemised receipts/bills/invoices.

3) Submit the completed claim form, along with the original, itemised receipts/bills/invoices to Generali Worldwide for claim processing by either: (a) mailing the documents to the address on the back of your ID Member card; or (b) delivering or mailing the documents to Generali Worldwide at Cayman Insurance Centre in George Town, Grand Cayman.

Please keep copies of all completed claim forms and accompanying receipts for your own records.

Is there any additional information required for dental claims?

Fully itemised dental receipts / bills / invoices should include the Patient's name, Provider's name/address/telephone number, condition being treated, date of service, type of service rendered and the tooth or teeth affected by treatment, amount charged and procedures performed. If this information is not shown, you may handwrite it on the bill / receipt and sign your name. If the claims being submitted are for prosthetic services (crowns, bridges or dentures), the following additional information must accompany the claim submission or it may be subject to denial:

• Date of service or the date of delivery of the product rather than placement of the order.
• The Dentist's narrative report (if a narrative report is not available, x-rays may be sent).
• For dentures and bridges, the date or dates of extraction of teeth involved. If it is a denture or bridge replacement, please include the date of prior placement and the reason for the replacement.
• If the claim is for a bridge or denture, we will need a chart of all other missing teeth in the mouth and their dates of extraction.
• If the claims being submitted are for periodontal services (gum disease), you must submit x-rays and periodontal charting along with your claim form.
• If the claims being submitted are for orthodontic services, where this is a covered service, you must provide the following information:
  - Date appliance placed
  - Number of months of treatment
  - Months of treatment remaining

If the claims being submitted are for services received as the result of an accident, you must always include pre-treatment x-rays and accident details.

How do I submit a vision claim?

1) Complete a separate, signed claim form for each family member for each benefit claimed. On the claim form, complete questions:
- Number 1 (Patient's Name),
- Number 1a (Insured's ID Number)
- Number 12 (Patient's or Authorised Person's Signature)

2) Attach your original, fully itemised receipts / bills / invoices.

3) Submit the completed claim form, along with the original, itemised receipts / bills / invoices to Generali Worldwide for claim processing by either: (a) mailing the documents to the address on the back of your ID Member card; or (b) delivering or mailing the documents to Generali Worldwide at Cayman Insurance Centre in George Town, Grand Cayman.

Please keep copies of all completed claim forms and accompanying receipts for your own records.

Is there any additional information required for vision claims?
Original, fully itemised receipts / bills / invoices should include the Patient's name, Provider's / Dispenser's name / address / telephone number, type of lens dispensed (i.e. contacts, single vision, bifocal, etc.), date the appliance (i.e. glasses) was delivered to the patient and the amount charged for each service/supply.

NOTE: the date of service should be indicated by the provider on their receipt. The date of service is the delivery date of the product rather than the placement date for the order.

Other information about the claim submission & reimbursement process?

• Reimbursement: All claims will be paid in US dollars and paid to the provider, unless otherwise indicated on the original receipt / bill /invoice.
• Claim settlement: Most claims can be settled promptly, usually within two to three weeks, if the claim form is completed correctly and itemised receipts / bills / invoices accompany the submission.
• Currency conversion: Currency conversions will be performed at the exchange rate applicable on the date the services were rendered.
• Translation of claims and receipts / bills / invoices: Your claims and original receipts / bills / invoices may be submitted in any currency and/or any language and will be translated by our service centre for processing. If not already indicated on the original receipt / bill / invoice, you should note the currency in which the claim was incurred.
• Claims submission to another insurer: If you or your eligible dependants have submitted the same claim to Generali Worldwide after it has been submitted to another plan, you must attach a copy of the bills that were submitted to the other plan and the explanation of benefits you receive from the other plan.
  
  
  

What is a 'deductible'?

A limited out-of-pocket amount you would be responsible for each year. This amount can vary based on your plan, your single/family status and the location and type of health service received.

What is 'co-insurance'?

An additional potential portion of medical expenses, which you may be responsible for paying, usually structured as a percentage amount. The maximum amount of co-insurance collected varies per service, location and amount of services used. Co-insurance is based on individual or family required amount.

What are 'other costs'?

Some additional expenses are required, including doctor visit co-pays (typically US$20), when using the US Preferred Provider Network.

Other expenses may include:

• Prescription drug co-pays (amount varies depending on whether drug is generic or brand name).
• Medical service charges in excess of the 'reasonable & customary' fees.
• Benefit penalties resulting from failure to pre-certify certain procedures and/or inpatient hospitalisation or emergency room care.
• Non-eligible expenses, i.e. services not covered under the terms of the plan or cost for services that exceed cover limits of the plan.
  
  
  

Do I need to get pre-approval (pre-certification) before seeking care?

Pre-approval (or pre-certification) is required for certain procedures / services under the Generali Worldwide Plan. Pre-certification involves the submission of certain information by your doctor to Generali Worldwide in order for services to be pre-approved - the entire process can be initiated with a phone call or email to Generali Worldwide in Cayman or Toronto.

The following services require pre-certification: all hospital admissions, outpatient surgery, treatment for inpatient mental disorders, all scope procedures, MRIs, CT Scans, vaginal ultrasounds and obstetrical ultrasounds exceeding two per pregnancy.

If pre-certification is not obtained prior to the services being rendered, cover for all services (including admission, surgery, scope, procedure and diagnostic testing) may be subject to denial or a reduction in your benefits to 50%.

How do I access care in Cayman?

You may seek care from the provider of your choice in Cayman. After you receive care, your doctor or hospital may bill Generali Worldwide directly and ask you for your portion of the payment due (typically they will request 20%). You may also pay your bill in full then submit receipts to Generali Worldwide for reimbursement.

How do I access care outside of the Cayman Islands?

You may seek care from the provider of your choice outside of Cayman. Please note, when you select a Generali Advantage Network Provider you will receive additional discounts. Click here to find a Provider.

Will doctors/hospitals accept my insurance card? What can I do to facilitate this?

There are many providers who accept direct payment from Generali Worldwide both on Island in Cayman, the US and other locations around the world. To facilitate this, ask them to call the Generali Worldwide Global Service Centre in Toronto, Ontario at: 1 877 618 7016 (toll free from Cayman). Access numbers can also be found on your ID card.

Providers can bill Generali Worldwide directly and charge you for the remaining amount due based on your plan of benefits. For providers who may not participate in our direct payment program, you would pay the bill in full and submit receipts for reimbursement as appropriate.

How long do I have to submit a claim?

You have up to 180 days to submit your claim from the date service was rendered.

How do I check the status of my claim?

You can check the status of your claims by visiting 'Research your Health Claims' in our Managing Your Plan section and logging-in.

What is an 'Explanation of Benefits'?

You will receive an Explanation of Benefits (or EOB) after your claims have been processed. This EOB will show you what percentage of health care expenses have been paid by the insurer. If reimbursement is due to you, a cheque will accompany your EOB.

Where and when do I receive a cheque for reimbursement of my claim[s] and in what currency?

Your EOB and any accompanying cheque (in US dollars, drawn on a Cayman bank) will be mailed directly to you at your employer's address.

How does Generali Worldwide determine what amount to reimburse?

Generali Worldwide calculates covered benefits and reimbursements due based on pre-defined limits of covered services in your plan and already established reasonable and customary fees for health care services received throughout the world.

My child is in college. Up to what age are they eligible for benefits?

Full-time student children are eligible for benefits up to age 25. After age 19, you must submit proof of student status each term of study (copy of schedule, bursar's statement, etc). Please submit this to Generali Worldwide and retain a copy for your records.

Can I continue my cover if I stop working for my current company in the future?

You can continue to receive cover for a total of 3 months after leaving your current company. You may either continue on your current plan for one month, and the SHIC Compulsory Plan for 2, or you may elect to receive cover under the SHIC Compulsory Plan for all 3 months. In either case, you would be responsible for the total monthly premium payment via your employer.

Who is eligible for cover?

Spouses and children are eligible for cover under the Generali Worldwide Health Plan. Common law spouses are eligible as defined under the Cayman National Health Law.

Are there any special requirements or considerations when seeking care in the US?

For non-US passport holders it is important to determine whether or not a visa is required for entry to the US. Consult your home country's state department website for more information on whether or not you require a visa for travel to the US. Though emergency visas can be issued, it can be a time consuming process and may delay necessary medical care.

Does Generali Worldwide pay the hospital directly?

Generali Worldwide has direct payment arrangements with the 550,000+ providers outside of Cayman. In addition, Generali Worldwide has relationships with doctors and hospitals in more than 200 countries around the world, many of which include direct payment agreements. To facilitate direct payments, you can contact the Generali Worldwide Global Service Centre in Toronto, Ontario in advance of your hospital stay so they may alert the facility and coordinate direct payment. If you are not able to coordinate this in advance, you can ask the hospital to contact the Generali Worldwide office through the toll-free number listed on your ID card to obtain information on your cover and authorise direct payment.

Are there other costs & requirements?

Some additional expenses may be incurred each year, including required 'co-pays' for pharmacy expenses and services received from doctors/hospitals within our Network. Please consult your benefits grid for specific co-payment amounts under your plan. Other expenses you could be responsible for may include charges for care that exceed pre-determined reasonable and customary fees and additional costs for benefits covered only at 50%.

Are there limits on covering pre-existing conditions?

There may be certain pre-existing condition limitations. Please consult your Plan Document or cover letter for further details on specific exclusions and limitations related to your plan.

What are 'reasonable and customary' fees?

Reasonable and customary fees are established procedure costs for health services. In some cases, doctors, hospitals and other health care professionals may charge in excess of what are considered usual fees. In those instances, you may be responsible for the additional charges. Because of this, it is important to understand expected fees up front, whenever possible. We encourage you to work with Generali Worldwide to help co-ordinate complex care and pre-determine related pricing.

What is a US Network Provider?

US Network Providers are US doctors and hospitals with whom Generali Worldwide has established an agreement to accept direct payment and bills for services based on pre-negotiated fees.