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Article 2.1 Free choice of medical practitioner, pharmacist and medical establishment 1. There shall be free choice of medical practitioner and pharmacist, as well as free choice of hospital, clinic or other medical establishment. 2. The Management Committee may prescribe or approve alternative arrangements for a particular area where it considers, in the light of special circumstances existing in that area, that such alternative arrangements would be more advantageous to the protected person and to the Fund. 3. For the purpose of these Regulations
the term "medical practitioner" shall refer to physicians or dentists who
are qualified and licensed to provide the various types of medical services
referred to in the Schedule of Benefits in the country in which their professional
services are used by a protected person.
1. Subject to the provisions of article 2.4, ordinary benefits shall be paid in respect of medical care in accordance with the Schedule of Benefits and with the conditions therein specified as regards: (a) any qualifying period or condition affecting periodicity of reimbursement; (b) the rate of reimbursement; (c) any limitation on the amount of benefit; (d) any items of expenditure excluded from reimbursement; (e) approval of treatment by the Medical Adviser. 2. Ordinary benefits shall be paid in respect of personal preventive care under conditions prescribed in the Administrative Rules. 3. In exceptional cases, the Management
Committee may, by unanimous decision, accord reimbursement of expenses
for health protection not provided for in this article. In such case, the
Management Committee shall prescribe the conditions governing the benefits
in question.
Article 2.3 Transfer of rights For the purpose of completing the qualifying
periods provided for under article 2.2 of these Regulations, a period immediately
preceding protection by the Fund during which the person concerned was
protected by a health insurance scheme of the United Nations or of a specialised
agency, or was otherwise protected by the ILO or ITU against health risks,
shall be regarded as equivalent to a period of protection under the Fund.
Article 2.4 Exclusion or limitation of liability for the payment of benefits 1. No benefits shall be paid : (a) in respect of medical care in case
of illness or injury
(b) in respect of medical care arising out of military service; (c) in respect of medical care incidental to surgery for aesthetic purposes (except in so far as such surgery qualifies for payment of benefit under the conditions governing Code 1.1 of the Schedule of Benefits); (d) in respect of medical care which the Medical Adviser considers to be useless, unnecessary or medically unsuitable; (e) in cases in which a protected person fails to comply with the orders of the attending medical practitioner; (f) in respect of medical reports, other than medical reports given for the purpose of pursuit of treatment, issued to administrative bodies, employers, etc. 2. Where, after consulting the Medical
Adviser, the Management Committee considers that particular expenses in
respect of which reimbursement is claimed are excessive, it may reduce
accordingly the reimbursement that would otherwise be payable under these
Regulations.
Article 2.5 Supplementary benefits 1. For purposes of this article and article 2.6, except as otherwise provided, "approved expenses" mean the actual expenses in respect of which ordinary benefit is payable under article 2.2, provided that, in cases where the amount of ordinary benefit is limited by any condition laid down in these Regulations, only that part of the expenses which qualifies for ordinary benefit shall be treated as "approved expenses". 2. For the purposes of calculating entitlement to supplementary benefit, account shall be taken of all items of expenditure in respect of which ordinary benefits are payable, except as otherwise stated in the Schedule of Benefits and in article 2.7.3. Where approved expenses incurred in any calendar year by an insured person and his dependants protected by the Fund exceed an amount (the "threshold") specified in the Administrative Rules, a supplementary benefit shall be paid on the amount in excess of the threshold, at a rate fixed by the Administrative Rules. 4. Supplementary benefits shall normally be paid after the end of the calendar year to which they refer but may, at the discretion of the Management Committee, be paid during the course of such calendar year. 5. The Management Committee may from time
to time vary the level of the threshold and the rate at which supplementary
benefits are payable. The Management Committee may also fix a lower threshold
for specified categories of insured persons.
1. The Fund shall not be liable to pay benefits in respect of approved expenses exceeding $150,000 in any calendar year for any insured person and his/her dependants protected by the Fund. In exceptional circumstances and after considering the financial position of the Fund, the Management Committee may, by unanimous decision, authorize the payment of further benefits. 2. For the purposes of this article, where
expenses qualify for payment of benefit under another health insurance
scheme or medical care service, only the amount of benefit paid by the
Fund shall be treated as "approved expenses".
Article 2.7 Protection by other health insurance schemes or services 1. Where the insured person or one of his/her dependants protected by the Fund is covered by another health insurance scheme, whether public or private, or by a public medical care service, the insured person is required — (a) to indicate to the Secretary of the Fund the name of the scheme or service concerned; (b) in connection with every claim for benefit he/she submits to the Fund, to supply the Secretary with a statement, together with supporting documents, listing the benefits received or to be received in respect of the expenditure in question from the scheme or service above-mentioned. 2. Where expenses qualify for payment of benefit under another health insurance or medical care scheme: (a) if benefit is claimed from the Fund as primary insurer, the expenses shall qualify for supplementary benefit, subject to the limitation imposed by paragraph 3; (b) if benefit is claimed from the other scheme as primary insurer, the expenses shall not qualify for supplementary benefit nor be taken into account in calculating the threshold." 3. In no case shall the benefits paid by
the Fund, together with such benefits as may be provided by the other health
insurance scheme or by the public medical care service (after deduction
of any allowances not intended to cover medical expenses) exceed the expenses
incurred by the insured person.
Article 2.8 Third party liability 1. The circumstances of any case of illness or accident of a protected person for which a third party is or may be fully or partly responsible shall be reported to the Fund as early as possible, in a manner specified in the Administrative Rules. 2. Where the Management Committee, or the Standing Subcommittee acting for that Committee, considers that third-party legal liability probably exists, it may after consultation with those concerned, require the insured and/or the protected person concerned or his/her survivors: (i) to assign his/her right of action, in a manner that may be specified in the Administrative Rules or in accordance with the directions of the Management Committee or the Standing Subcommittee, in which case the benefits under these Regulations shall be payable; (ii) to take the necessary action against the third-party jointly or in close consultation with the Fund. In such a case, no benefit shall be payable with respect to medical costs for which a third-party is or may be liable. 3. Notwithstanding paragraph 2 (ii) above, where the insured person or other persons concerned has taken such action as may be required by the Management Committee to obtain compensation from the third-party, the benefits provided for under these Regulations shall be paid: (i) in full, where no compensation is recovered from the third-party; (ii) after deduction of any compensation paid by the third-party with respect to heads of damage for which the above mentioned benefits are paid. (iii) The legal costs incurred in any action that may be required or approved by the Management Committee shall be equitably shared between the Fund and the insured person or other persons concerned in the manner decided by the Management Committee or the Standing Subcommittee, having regard to the amounts recovered for the Fund. 4. The insured and/or the protected person
or his/her survivors shall give the Fund all necessary information and
assistance in connection with such legal action. The insured and/or the
protected person or his/her survivors shall not settle any such action
or any claim against a third-party without the consent of the Fund.
In the event of illness or accident attributable
to the performance of the official duties of an insured person, in respect
of which medical and allied expenses are payable by the employing organization,
benefits from the Fund in respect of such expenses shall not be due. However,
benefits may be initially paid, subject to reimbursement by the insured
person upon settlement of his/her claim by the Organization concerned.
Article 2.10 Payment of benefits 1. In accordance with article 1.1, paragraph 2, benefits shall normally be paid only to the insured person. In exceptional circumstances, payment may be made to the person who has actually paid the expenses in respect of which reimbursement is claimed. 2. Benefits shall normally become payable on submission of evidence that the expenses giving rise to reimbursement under these Regulations have been paid. Where proof of payment is not given at the same time as the request for reimbursement, the insured person may be called upon to furnish all necessary elements of proof. In exceptional circumstances advances on benefits may be authorized for obligations already incurred. 3. Bills sent to the Fund more than 21 months after the date when they were made out or more than 27 months after the completion of the treatment to which they refer shall not entitle the insured person to receive benefits from the Fund. Bills sent to the Fund more than 9 months after an insured person has left the Fund shall not be reimbursed regardless of the date at which the treatment to which they refer was given or the date when they were made out. 4. Where doubts exist as to the authenticity or accuracy of a bill or as to entitlement to benefit, benefit shall not be paid unless and until the insured person provides information that satisfactorily removes such doubts. 5. Any sums in excess of the entitlements
to benefits laid down in these Regulations paid by the Fund, shall be repaid
to the Fund by the insured person, in the same manner as provided in article
2.10bis, paragraph 2.
Article 2.10 bis Agreements between the Fund and providers of services 1. The Fund may enter into agreements with providers of services in order to develop means which appear from time to time desirable for the proper administration of the Fund and prompt delivery of services. Such agreements may contain arrangements to guarantee bills and/or to make payment of the sums guaranteed directly to particular providers or classes of providers of services. 2. Where arrangements to pay benefits directly to providers are made, the following conditions shall apply: (a) bills presented to the Fund by the provider shall, when the insured person has certified in writing that the services covered by the bill have been received, be paid directly by the Fund to the provider; (b) where the insured person is a serving official, the part of the bill for which he/she is responsible shall be paid to the Fund by the Organization employing the insured person and be deducted from his/her salary; (c) any other insured person shall repay
to the Fund the part of the bill for which he/she is responsible; if he/she
fails to do so within one month of being requested, the Fund may set off
the amount due to it against benefits payable to him/her or take other
appropriate action.
Article 2.11 Forfeiture and suspension of benefits By decision of the Management Committee, an insured person’s entitlement to certain benefits may be forfeited or suspended in whole or in part, subject to the provisions of article 5.3 (a) if he/she does not comply with the provisions of these Regulations and the Administrative Rules; (b) if it is proved that he/she fraudulently attempted to obtain benefits to which he/she was not entitled; (c) if he/she or one of his/her dependants protected by the Fund refuses to undergo a medical examination as requested by the Management Committee or the Medical Adviser of the Fund; or (d) if he/she is in arrears in the payment
of voluntary contributions.
Article 2.12 Right of pre-emption for the Fund of appliances no longer needed 1. When an appliance to which this article applies and in respect of whose acquisition the Fund has paid benefit under Code 5.4 and Code 5.5 (Wheelchairs and other appliances) of the Schedule of Benefits is no longer needed, the insured person (or, in the case of death, his heirs or successors) shall so inform the Secretary of the Fund and offer the appliance to the Fund. 2. The Management Committee, by notice addressed to the insured person or other person concerned within 30 days of receipt of the offer, may decide to buy the appliance, on payment of the net amount (after receipt of ordinary benefit and the appropriate proportion of supplementary benefit) borne by the insured person at the time of its acquisition. 3. The Management Committee may dispose of the appliance on such terms as it may deem in the best interest of the Fund. 4. This article applies to —(a) any appliance
acquired at a cost of not less than $500;(b) any other appliance specified
by the Management Committee by Administrative Rules or by decision notified
to the insured person.
The Management Committee may from time
to time, and for such duration as it may specify, establish the rate of
exchange between the US dollar and specified other currencies to be applied
in determining entitlements, maxima and contributions fixed in US dollars
in these Regulations or any Administrative Rules.
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