Chapter VI of Administrative rules

CODE 1.5  ( FUNCTIONAL REHABILITATION)

1.
(a) The maximum approved expenses are set at US$ 85 per session (i.e. ordinary benefit will be limited to US$ 68 per session). The maximum number of sessions reimbursed is set at 30 sessions for any one medical condition per protected person per calendar year.

(b) The number of sessions may be exceeded for cases of rehabilitation after an accident or major surgery or neuro-muscular disease, where the Medical Adviser confirms the necessity and indicates the number of additional sessions.

2 . Benefit is not payable in respect of cures of less than two weeks or for more than one cure in any calendar year.

3 . Treatments listed below are eligible for reimbursement:

- physiotherapy
- kinesitherapy
- chiropractice
- orthophony/logopedy
- orthopty
- osteopathy
- ergotherapy (in a hospital)
- lymphatic drainage (if lymphatic system affected)
- chiropody
- acupuncture and mesotherapy performed by a physician

Back to Top

CODE 1.6 (OUT PATIENT MEDICAL NURSINGSERVICES FOR AN ACUTECONDITION)

The maximum approved expenses are set as US $ 2.500 per protected person per calendar year (i.e. ordinary benefit will be limited to US $ 2.000 per protected person per calendar year), unless the Medical Adviser certifies that nursing is still for an acute condition.

Back to Top

CODE 1.7 (PSYCHIATRY, PSYCHOANALYSIS OR PSYCHOTHERAPY)

The maximum is set at 60 sessions or US$ 6,000of approved expenses (i.e. ordinary benefit US$ 4,800), whichever comes first, per person in any period of three calendar years.
Back to Top

CODE 2.2 (ACCOMMODATION IN HOSPITALOR CLINIC)

1. The maximum approved expenses and maximum ordinary benefit for accommodation in a hospital or clinic for examination, diagnosis or curative treatment (reimbursable at 80 per cent under Code 2.2) shall be the cost of semi-private accommodation (two or more patients in a room) subject to the following ceilings:
 

2. Where the institution in question offers only private accommodation, the following rules shall apply:

(a) in Europe, Canada, the United States, Japan and South Korea, the cost of semi-private accommodation, for the purpose of fixing the maximum approved expenses, shall be deemed to be 80 per cent of the cost of the least expensive private room;

(b) in all other countries, the cost of semi-private accommodation shall be deemed to be the cost of the least expensive private room.

3. When a global charge is made, one-third of the global charge will be attributed to accommodation and two-thirds to medical care.

Back to Top

CODE 2.3 (ACCOMMODATION FOR CONVALESCENCE / FOLLOW-UP TREATMENT)

1. The maximum approved expenses per day are set at US$ 170 (and the ordinary benefit per day is limited to US$ 136).

2. When a global charge is made, one-third of the global charge will be attributed to accommodation and two-thirds to medical care.

Back to Top

CODE 2.4 (CURES)

1. The maximum benefit for cures is set at US$ 20 per day.

2. Benefit is not payable in respect of stays for cures of less than two weeks. Benefit is limited to one cure and a maximum of fourteen days in any calendar year.

Back to Top

CODES 2.5 and 2.6  (LONG TERM NURSING SERVICES)

1. The maximum approved expenses and maximum ordinary benefit for long term nursing services shall be subject to the following ceilings:
 

Applicable from: 1 January 2004
	In an institution		At home
	Max. approved expenses: US$ per day	Ordinary benefit : US$ per day	Max. approved expenses per month (US$)	Ordinary benefit per month (US$)
	138	110.40	3 450	2 760

2. a) Benefit in respect of long term nursing services is subject to approval by the Medical Adviser.

b) A physician has to confirm, at least once every calendar year, the nature of the nursing care needed and that the institution or personin question can provide it.

3. In the event of interruption of payment of benefits for less than 6 months, the benefit shall continue to be paid on the same basis as previously.

Back to Top

CODE 3 (PRESCRIBED MEDICAMENTS)

1. Expenditure for items and supplies included in the following (non exhaustive) list has been identified by the Management Committee as excluded from reimbursement under Code 3:

- small adhesive dressings, or household bandages
- distilled water and mineral waters
- dentifrice (any kind)
- tooth-brushes
- toothpicks
- cleaning tablets for dentures
- personal hygiene products, such as cleaning cloths, talc, ear swabs, etc.
- sea salt
- bath salts
- cotton wool
- corn plasters
- pedicure products
- sunburn lotions
- dietetic products
- deodorants
- shampoos and hair restorers
- household disinfectants
- special cosmetics, notably those for sensitive or allergic skin
- cleaning liquid for contact lenses
- alcohol, wine and liquors

2. Where pharmacy items are purchased more than once, the prescription must specify clearly how many times or for which period they are to be repeated. A simple indication such as Ato be repeated@ will be considered as a prescription for one renewal only.

3. Once every 12 months a new prescription will be required in all cases.

Back to Top

CODE 4 (DENTAL CARE)

1. No benefit will be payable in respect of treatment undertaken within one year of protection.

2. Thereafter, the maximum approved expenses are set at US$ 1,500 per protected person per calendar year (i.e. ordinary benefit US$ 1,200).

3. The balance of approved expenses remaining at the end of any calendar year shall be carried over and added to the entitlement for the following year, subject to a maximum carry over from one year to the next of US$ 4,500 (i.e. ordinary benefit US$ 3,600).

4. The following shall be treated as cases of ordinary illness for the purpose of benefit:

(i) cranio facial malformation;

(ii) facial fissures;

(iii) orthographics:

(iv) bone grafts:

(v) temporo-mandibular articulation.

Back to Top

CODE 5.1 (OPTICAL APPLIANCES)

1. No benefit shall be payable in respect of acquisition or repair within one year of protection.

2. Thereafter, the maximum approved expenses are set at US$ 320 per protected person per calendar year (i.e. ordinary benefit US$ 256).

3. Within the maximum specified in paragraph 2, benefit for frames shall not exceed $ 100.

4. The balance of approved expenses remaining at the end of any calendar year shall be carried over and added to the entitlement for the following year, subject to a maximum carry over from one year to the next of US$ 640 (i.e. ordinary benefit US$ 512).

5. The Management Committee may authorize payment of benefit beyond the maximum where, as a result of surgery, the condition of the eyes requires changes of lenses.

Back to Top

CODE 5.2 (HEARING AIDS)

1. No benefit shall be payable in respect of acquisition or repair within one year of protection.

2. The approved expenses shall be limited to US$ 3.750 (i.e. ordinary benefit US$ 3,000) for any three calendar years.

Back to Top

CODE 6.3 (OTHER MEDICAL TRAVEL)

1. Definition of Area: radius of 30 km outside metropolitan city limit.

2. Benefit shall be due subject to prior approval by the Medical Adviser who:

(i) certifies that adequate medical care cannot be obtained in the duty station/area of residence;

(ii) identifies the nearest place  where adequate medical care can be obtained.

3. Normally, travel costs are paid only if the care is obtained in the nearest place identified by the Medical Adviser under paragraph 2 above.

4. The Management Committee may nevertheless approve payment of travel costs, not exceeding the amount of the cost of travel to the nearest place identified by the Medical Adviser, for treatment at another place if it considers that compelling reasons exist for treatment to be sought elsewhere.

5. The Management Committee may also approve the payment of the actual cost of travel to a place other than the nearest place identified by the Medical Adviser, where it considers travel to such other place to be advantageous to the Fund in view of the particular circumstances and the overall costs involved.

6. Benefit will be paid only in respect of the cost of the cheapest ticket by the cheapest mode of transport available.

CODE 7 (FUNERAL COSTS)

The maximum benefit is set at US$ 500.-.

Back to Top