HOSPITAL CASHBACK PLAN FOR GROUPS
1. THE CONTRACT
1.1 The Provisions and Benefits in this policy document, together with the application, and any declaration made by the Life Assured, constitutes the entire contract; and cannot be waived, or modified, except by an authorized official of the Company.
2.1 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 events that is traceable to psychiatric trauma and the Insured Person’s state of mental or physical health prior to the event;
· Non visible soft tissue injuries excluding clinically confirmed ligament and tendon damage;
2.2 CHILD means an unmarried dependent child, step-child, illegitimate child or adopted child (legally or by custom) of the Life Insured and includes a child who is over 21 and becomes dependant on the Life Insured by reason of mental or physical incapacity during the currency of the Policy. A dependent child that has attained the age of 18 years or 24 years if NOT a full time student shall no longer be covered under this policy.
2.3 DAY means a period of 24 (twenty-four) consecutive hours of hospitalisation, including the day of admission but excluding the day of discharge.
2.4 DEPENDENT ADULT means:
2.4.1 Anyone who meets the definition of a child as per this policy and is a full time student at a recognised institution. Cover for such lives ceases at age 24 .
2.4.2 A parent to the Principal Life Insured, or his/her spouse, who is financially dependent on the Principal Life Insured. Cover for such lives ceases at age 70.
2.4.3 A total maximum of two parent nominations and two parents-in-law nominations is permitted.
- HOSPITAL is defined as an institution which:
- Is licensed in accordance with the applicable laws of the Republic of Malawi and located in the Republic of Malawi;
- Is primarily engaged in providing, for compensation from 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, 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.
- ILLNESS means sickness or disease contracted and commencing during the term of this Policy.
- INSURED PERSON / LIFE INSURED means the person(s) who is covered under this policy and is/are a resident(s) of Republic of Malawi
- PHYSICIAN means a medical practitioner duly qualified, registered, licensed and practicing within the scope of his/her license pursuant to the laws of Malawi. 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.
- POLICY OWNER shall be the group covered under this policy and is the initial payer of the Policy unless the Company is advised otherwise in writing.
- 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, including 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. Pre-Existing Medical Conditions will however be covered in full after the first 24 (twenty-four) Premiums have been paid from the Date of Commencement or Reinstatement Date.
PRINCIPLE LIFE INSURED means the primary life covered in a group under this policy and has the option of choosing his or her spouse and
- other dependents for cover provision as per the terms and conditions of the policy. The minimum age is 18 and the maximum age is 70.
- SPOUSE means the person married (whether by civil, customary, tribal or religious union) to the Principle Life Insured. The minimum age is 18 and the maximum age is 70.
- CURRENCY OF PAYMENTS
3.1 All payments to or by the Company, shall be made through the company’s digital platforms or bank.
- GENERAL TERMS AND CONDITIONS
4.1 Hospital Cash Back Benefits will be payable for hospitalisation at any registered hospital in the Republic of Malawi.
4.2 Cover will commence on the first day of a given month upon successful receipt of the first premium and shall be renewed thereafter after expiry of 12 months unless the policy is cancelled as per the provisions of the policy.
4.3 Reinstatement of a lapsed Policy may be effected by the Company at their 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).
4.3 The Policy may be cancelled at any time by the Policy Owner by giving one calendar months’ notice in writing. The Company may cancel this Policy by giving one calendar months’ notice in writing to the Insured Person / group’s last known address.
4.4 All Benefits under this Policy will be forfeited if a claim is fraudulent in any respect or intentionally exaggerated and the Company will cancel this Policy and all premiums paid hereunder will be forfeited. The Company further reserves the right to limit any duration of hospitalisation if, in the opinion of our independent Medical Officer, the duration of admission is not justified.
4.5 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 Group / Person or Beneficiary shall supply in writing at his/her own cost any reasonable information that the Company may request.
4.6 The Company will pay the Cash benefit as stated on item 5, subject to there being no outstanding premiums, directly to the person who is entitled to receive it or group representative on proof of the hospitalisation of a Life Insured as a result of an accident or illness, provided that such hospitalisation occurs during the term of this Policy and outside any applicable waiting periods
4.7 Policy for a member who has exhausted benefits can be reinstated for 3 (three) times at 100% additional premium.
4.8 WAITING PERIOD
There is a waiting period of 1 month from date of commencement of policy or reinstatement in the case of lapsed policies. 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.
4.9.1 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.
4.9.2 A maximum of 28 (twenty-eight) days of hospitalisation is allowed per policy per year.
4.9.3 Children aged under 1 year (age last birthday) will not be covered by the policy.
4.9.4 The Benefit in respect of Children younger than 5 years (five) (Age Last Birthday) will be paid at 50% of the normal Daily Cash Benefit.
4.9.5 Re-hospitalisation within 10 (ten) days for the same cause counts as the same event.
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 life 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 as it appears in our records at that time.
4.11 IMPORTANT NOTE: This Policy is classified as a Health Insurance product and should not be seen as a Medical Aid Scheme and does not provide cover equivalent to that of a Medical Aid Scheme.
- SCOPE OF INSURANCE:
5.1 If during the Period of Insurance any Insured Person suffers Sickness or Bodily Injury which results in any Sick or Injured Person’s Hospitalisation, Smile Life Insurance (“the Company”) will pay the Insured Person the Weekly Cash Benefits as shown below:
Days of Hospitalization
Amount Payable / Sum Assured ( MK)
Between 1 day to 7 days
Between 8 days to 14 days
Between 15 days to 21 days
Between 22 days to 28 days
5.2 The benefits will be paid provided:
- Hospitalisation occurs within 30 (thirty) days of any injury or sickness;
- There has been a minimum of 48 hours of continuous hospitalisation due to Sickness or Bodily Injury;
- The sickness or injury was suffered during the term of the
- The sickness or injury falls within the policy terms and conditions
5.3 AUTOMATIC ANNUAL INCREASE AND PREMIUM GUARANTEE
The Weekly Cash Benefit as set out in this policy will increase by 6% each calendar year commencing 12 (twelve) months from the commencement date of this Policy. The monthly premium will increase by 10% each calendar year. The premium (excluding the annual increase) will be guaranteed for the first 24 (twenty-four) months.
The Company reserves the right to reassess rates after this period.
- The premium payable is MK3,900 only per year.
6.2 All benefits under the policy are based on the assumption that these premiums will be paid in full and the onus is on the Group to ensure that they reach the Company as and when due. Should the policy be cancelled on request then cover for the group on the policy shall cease from the date of cancellation and any premium received from that date will be refunded by the Company.
6.3 Should the premiums not be paid within 30 days of the premium due date or policy commencement date, the policy will lapse and all benefits will fall away.
6.4 At the sole discretion of the Company, the policy may, at any time within one year of lapse be reinstated, in full, upon payment of all arrears, which may include an annual
6.5 The policy is not valid until the Company has accepted the application.
In the event of a hospitalisation for more than 48 hours, the group representative will need to lodge a claim so that it can be assessed. Claims can be made as follows:
- Lodge a claim through USSD Application or Whatsapp Chatbot;
- Visit us at any of our official offices;
- Contact us on 0882777777 or 0111832211
The Claims Department will require information including the following:
- Policy number of the insured
- Name of person in hospital
- Date of admission and discharge
- Cause of hospitalisation
- A phone number or e-mail address
- All other relevant documentation (see below), signed and certified
by a Commissioner of Oaths, e.g. bank manager or police officer
Other Relevant documentation
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
- 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 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
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
- 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, parachuting, hang-gliding, winter sports involving snow and ice, professional sports or racing other than on foot will not be covered.
- 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.
- Confinement for routine physical or any other examination where there are no objective indications or impairment in normal health, will not be covered.
- Pre-Existing Conditions as defined herein during the first 2 (two) years from the Date of Commencement or Reinstatement of the Plan 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, plastic surgery 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 will not be covered.
- Hospitalisation as a consequence of breast reduction and enlargement operations, treatment of cystic fibrosis will not be covered.
- Dental conditions and treatment will not be covered.
- Any hospitalisation not recommended by a qualified physician 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.
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.
- No claims as a consequence of illness will be considered during the waiting period.