Professional Documents
Culture Documents
BETWEEN
GLOBAL PROPERTIES
AND
A. INTRODUCTIONS 3
B. GROUP MEMBERSHIP 4
C. RENEWAL 4
D. SUBSCRIPTION 4
E. BENEFITS 4
F. AMENDMENTS 5
Takaful Gambia Limited (hereinafter referred to as TGL or the Company) and (GLOBAL
PROPERTIES) (hereinafter referred to as “the sponsor”)
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A. INTRODUCTION
1. The sponsor (Company name/ hereafter refer to as the client) agrees to operate a
TAKAFUL GAMBIA LIMITED (TGL) HEALTH SCHEME (hereinafter
referred to as “the group”) whereby, in return for subscriptions paid by the
sponsors, TGL will settle/reimburse all bills resulting from medical attention
necessitated through sickness or accident and carried out in a hospital or health
institution in accordance with the rules of TGL’s Group Scheme and table of
benefits (as set out in schedule (B) of this agreement) both as amended from time
to time in accordance with rule 6.
2. The sponsor will, at his own expense, appoint a group secretary to act on behalf of
the sponsor and who will administer the group in accordance with the terms of
this agreement and such notes to group secretaries as Company may issue from
time to time.
3. In the event of the sponsor going into liquidation (except where the liquidation is
for the purposes of bona fide group reconstruction, take-over or amalgamation) or
becoming bankrupt, or if the sponsor fails to pay any subscriptions within one
month after the due date, TGL shall be entitled to terminate this agreement
immediately without prejudice to its rights of action in respect of any previous
breaches of this agreement.
6. All words and phrases used in this agreement shall have the meaning employed in
the rules of TGL Group Health Scheme for the time being.
7. The sponsor will ensure that copies of the rules and table of benefits will be
available to Group Members at all times.
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B. GROUP MEMBERSHIP
For the purpose of this rule, partners or sole proprietors of firms shall be as
employees.
2. All employees who become eligible for membership during the Certificate period
shall be permitted by the sponsor to submit the prescribed application form to the
Company subject to the terms of the registration being agreed, inclusion in the
group will be subject to a short term subscription payment.
4. Group members (together with such eligible dependents are covered by this
agreement) who leave the sponsor’s employment or otherwise become ineligible
for continuing inclusion in the group in any year may, with the sponsor’s consent,
remain in the group until the end of that month.
C. RENEWAL OF AGREEMENT
The agreement shall be for a period of 12 (Twelve) Months from the date of
commencement shown in schedule A and subject to the rules and consent of
TGL, may be renewed from year to year unless the number of employees in
the group falls below the minimum requirement of Ten employees (as referred
to rule B 1).
D. SUBSCRIPTIONS
i) To pay on the date hereof and thereafter on each annual renewal date the
rates of subscription set out in schedule (C) as it may be amended from
time to time in accordance with rule 6; and
E. BENEFITS
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F. AMENDMENTS TO AGREEMENT
TGL may alter this agreement, the table of benefits and subscriptions and the
rules from time to time, but any such alteration shall not take effect until the next
annual renewal date except when otherwise agreed between TGL and the sponsor.
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TGL’S GROUP (ANNUAL CONTRACT)
SCHEDULE A
CERTIFICATE DETAILS
This Schedule forms part of the Policy for GLOBAL PROPERTIESGroup Health
Scheme
STAFF
7. VARIATION TO AGREEMENT:NIL
DATE: DATE:
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SCHEDULE B CERTIFICATE NO:TBR01SIN000000020
TABLE OF BENEFITS
THIS TABLE AND ITS NOTES MUST BE READ IN CONJUNCTION WITH RATES.
BENEFIT MAY BE CLAIMED WHEN TREATMENT IS GIVEN OR CONTROLLED
BY SPECIALIST, AS SET OUT IN THE RULES.
MEDICAL COVER
SPECIALIST FEES
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SCHEDULE B (CONTINUED)
EVACUATION COVER
NOTES ON BENEFITS
1a. 90% of the cost on dental treatment shall be covered provided such services are
obtainable from members to our Participating Clinics and the maximum annual
limit is GMD5, 000.00. (Five ThousandDalasi) per person per annum.
This includes the cost of glasses and frames which are divided into
a) Frames –D1, 500.00 limit b) Glass –D3, 500.00 limit.
Optical lenses and frames are replaceable in every twoyears of first acquisition
except one`s eyesight deteriorates following doctor’s recommendation and in such
case, only the change of lenses would be allowed.
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SCHEDULE B (CONTINUED)
2. Physician’s fees and drugs
Benefits 3 and 6 are payable only when an-in- patient is currently entitle to
receive benefit 1 in accordance with the rules as in Rule 7.
5. Reimbursement
Request for refund without prescriptions and receipt will be repudiated, and
refund with supporting documents should be submitted not later than end of
the preceding month.
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SCHEDULE C CERTIFICATE NO: TBR01SIN000000020
GLOBAL PROPERTIES
STAFF
1. These rules must be read as a whole and in conjunction with the table of benefits
and subscriptions, the members enrolment form, the membership card and the
terms attached to the membership card issued to the member. These documents
are part of an agreement (“The Agreement”) which is a contract between the
sponsor and the Company. The notes to the tables of benefits are part of the
contract.
2. No Changes to these contractual terms will be valid and effective unless when
made as a matter of record and duly confirmed by the Company. Unconfirmed
verbal communications cannot override the written terms of the contract or
amount to any agreement to vary any of its terms.
3. All applications for enrolment of members and their eligible dependents are
subject to the requirements set out in the Company’s enrolment form. The
applicant must make full and complete written disclosure of all the information
required by the Company. Eligibility for membership shall be restricted to persons
who are resident within the Gambia and aged less than65year, for employees and
spouse and up to 18 years for child dependents.
4. The contract is an annual one between the Company and the sponsor.
Membership shall be renewable from year to year subject to the terms and
conditions. Application may be made at the annual renewal date to vary the terms
of a registration. Acceptance for any higher rates of benefit shall not apply to
any condition or complaint existing at the time of the Company’s acceptance for
which there was then a forcible need for treatment or for consultation with any
medical practitioner unless such forcible need was fully disclosed in the
enrolment form accepted by the Company.
6. All claims are subject to the general rules contained in Rule 6 and special
Rules relating to:
Charges by Hospitals for accommodation (Rule 7)
Charges by Practitioners who are not specialist (Rule 8)
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Mental conditions (Rule 9)
6.1 It must have been necessary for the treatment to be given by a specialist.
The treatment must have fully necessitated the expert knowledge and
experience of a specialist trained in a specialty relevant to the patient’s
medical condition.
6.2 The treatment must have been based on established medical practices.
Benefits are not payable for any experimental or unproved treatment unless
all cost is incurred with the Company’s prior written agreement. (We
believe that a positive approach to cost containment is in everybody’s
interest. We may also seek written assurance as to their usual levels of
charges from anybody whose fees are claimed from the Company.
Obviously no Takaful provider could normally be expected to accept any
extra charge which had been made simply because the patient was known to
be person covered. If we accepted such practices they would either inflate
levels of subscription or reduce our scope for assisting our other members).
6.3 Cover for evacuation is in any year limited to only members of the Tugal or
Duniya. The purpose of evacuation cover is to meet the reasonable cost
of the patient’s removal and journey to the nearest hospital that facilities are
available to treat a medical condition when all such cost are incurred
necessarily and exclusively for facilitating in-patient treatment in hospitals
by specialists which, on medical grounds, cannot locally be provided. In
such circumstances evacuation benefit will also be payable for the
reasonable cost of travel of the member or any eligible dependent on the
member’s registration who, of medical necessity has to accompany the
patient.
6.4 All claims are subject to any maximum amounts of benefits stated in the
Contract. Claims are assessed by reference to the rules and schedule of
benefits as at the date the services were received. The patient must have
been included in a current Takaful company scheme enrolment at the time
of receiving the services.
7. Hospital charges: Additional conditions apply to claims for any charges by the
hospitals for accommodation. These are as follows.
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Benefit for in-patient and day-case treatment is payable for each day the use of the
accommodation was essential for receiving a course of treatment by a specialist.
The maximum rate for inpatient/accommodation shall not exceed D750.00 (Seven
Hundred Fifty Dalasis) per day for a period not exceeding 30 days.
Benefits are not payable for any use of hospital accommodation which is arranged
or continued for purposes of convalescence, rehabilitation or general nursing, or
are mainly for any custodial, supervisory or domestic reasons.
8. Charges by non-specialists: Claims for services of any other practitioner are not
eligible for benefit unless:
ii) The specialist had specifically referred the patient to that practitioner
before any of the services were provided.
iii) Qualified nurse services: The services must have been provided on a
Specialist’s recommendation, in the patient’s home, as an immediate part
of an overall course of in-patient treatment previously received from that
specialist. The treatment previously given by the specialist must also have
been eligible for benefits.
A) Treatments for any pre-existing conditions are not covered. However, this
exclusion will apply to all conditions:
iii) The treatment was not excluded by the terms attached to the scheme
opted for.
D) Pregnancy or childbirth: the Company will meet local costs related to their
medical conditions cause by complications of delivery necessitating any
unforeseen increase in charges to an in-patient made by hospitals and/or
specialists, provided such costs fall within the stated D20,000.00( Twenty
Thousand Dalasi)
The exclusion for termination of pregnancy will not apply in any cases where
it is necessary to remove a fetus as an essential preliminary step to major
medical procedure fulfilling the definition of treatment in the Rules e.g.
surgery in cases of serious accident. However, the exclusion will apply in all
cases where removal of live fetus is carried out for any social, domestic or
psychological reasons. We cannot make any discretionary payments for any
sterilization carried out for such reasons).
F) Supportive treatment for renal failure, including dialysis. This exclusion will
not apply if:
i. The patient had been in hospital for the immediate purpose of receiving
a kidney transplant, or
ii. The costs were incurred in connection with acute secondary failure when
the dialysis was part of an intensive care.
H) Treatment arising from any cosmetic surgery. Any cosmetic surgery arranged
for any kind of psychological reasons will not be covered. This exclusion also
applies to treatment for any complications resulting from cosmetic surgery.
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Any surgery that is entirely for purposes of restoring a patient’s original
appearance following an accident will not be considered “cosmetic” if the
surgery was undertaken during the course of treatment of the accident.
I) Any cost arising from nuclear or chemical contamination, war, invasion acts
of foreign enemies, hostilities (whether war be declared or not), civil war,
rebellion, revolution, insurrection, or military or usurped power.
J) Charges for services received in health hydros, nature cure clinics or similar
establishments.
L) The covered persons who travel to the USA or Canada for the purpose of
receiving medical or surgical treatment or treatment received in the USA or
Canada.
All treatment received in the USA & Canada must also have been specifically
pre-authorized by the Company (Takaful Gambia limited)
We have a duty to sponsors to ensure that valid claims are paid and that all
claimants are dealt with on an equal footing. With the great majority of claims,
all we need is the medical information supplied in the claim form and your bills.
However, there are occasions when we need further information to ensure that
the funds subscribed by all our other sponsors are being properly applied. If we
are to discharge those responsibilities, we must receive the necessary powers.
There is consequently no right to benefits if the pre-conditions set out in this rule
are not observed by the claimant.
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b. the Company may:-
c. All statement made by the claimant (or by any person acting on the
claimants authority) must have been true and complete to the best of the
claimants knowledge and belief.
d. If the claim arises from an accident or other events believed to have been
the result of the negligence of another party, the Company must be
notified in without delay. The claimant must continue to keep the
Company fully informed in writing and take any steps which the Company
may reasonably require to include all medical expenses in any claim upon
the other party with a view to reimbursing the Company outlays.
e. All subscriptions due from the sponsor must have been paid in full. This
pre-condition would be satisfied if any arrears of subscriptions due from
the sponsor under the terms of the Agreement were subsequently paid in
full.
12. Benefits shall be payable in GMD or where requested by the member the currency
of the bill for treatment. Where benefits are payable for expenditure incurred in
some other currency, the rate of exchange applicable to the payment of benefit
shall be the average rate of exchange at the date on which providers of services
submitted their accounts to the claimant or if receipted accounts are submitted by
the claimant, as at the average rate of exchange at the date on which the accounts
were paid.
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ADMINISTRATION
The Company shall periodically debit the account of the sponsor for the 10%
contribution on out-patient, drugs/Gyny/dental/optical.
The Company cost may alter these rules or the table of benefits and apply such
alterations as from a member’s annual renewal date.
Changes to the contract may also be sent to sponsors at any time on the basis that
they will apply generally to all the Company Group Scheme from a given future
date irrespective of whether that date is an annual renewal date for any group or
member.
Any accidental omission or failure by the Company to notify the member or the
sponsor of any such alterations will not invalidate the alterations.
Information supplied to the company will become part of the data held by the
Company and access to such data may be granted by the Company to others on a
strictly confidential basis in the course and for the purpose of the efficient
administration of the Company’s Group Takaful Scheme.
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TERMINATION OF THE CONTRACT
1. The Company may at any time terminate the membership or subject it to different
terms on the happening of the following events:
a) any person included in the member’s enrolment has at any time failed to
observe the rules of this agreement to act with the utmost good faith, or has
ceased to be resident in The Gambia
b) If the client breaches any of the terms and conditions of this agreement for any
reason specified in the agreement, or
e) The person covered through the secretary may at any given time of the
agreement terminate the contract provided a one month’s notice is given to the
company in writing prior to the termination.
This is an annual contract and coverage shall terminate for all covered persons, if
the contract expires. No payment will be effected by the Company for expenses
incurred after or before the certificate period.
DEFINITIONS
The following expressions, where used anywhere in the contract, will have the meaning
set out below:
SPONSOR: The employer with whom the company has agreed to operate the Company
Group Scheme.
DATE OF ISSUE: The date on which a membership card and the terms attached to the
membership card for a current enrolment was first issued in respect of a member, or as
the case may be any eligible dependent.
GROUP MEMBER: a person included in the group from among those designated as
being eligible for inclusion in accordance with the terms of the agreement.
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ELEGIBLE DEPENDANTS: a member’s spouse, and unmarried children under 18
years of age and expressed dependent at the date of application or the annual renewed
date, provided they had been included in the application form.
ANNUAL RENEWAL DATE: The date on which the annual renewal of the contract
falls due.
IN-PATIENT: A patient who occupies a hospital bed overnight. Charges to this bed
excluding drugs and medical care are covered in full provided the cause for the in-
patient is not exclusion on the policy. The cover for in-patient resulting from dental,
optical, gynecology, maternity or childbirth shall always be referred as per limit in this
certificate on such cost and in accordance to the limits stated in Schedule B.
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SCHEDULE D
SIGNED BY:
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