SUITS AGAINST THIRD PARTIES. Nothing in this Policy shall render the Company liable or be responsible or to be added as a party in any way whatsoever to any suit for damages which may be instituted by the Policyholder or an Insured nominated under this Policy against any provider of Medical or Dental Services or Treatments, wherein such may sue the same for reasons of neglect, malpractice or other causes arising from his/her acts or omissions in the treatment or examination of any Insured under the terms of this Policy Notes:- 1. The following surgical schedule indicate the percentage payable on the insured benefit for Surgeon Fee stated in the Policy Schedule of Benefits for the corresponding surgical operation. Where shown, the Bonus payment on major surgery will be payable in addition to the percentage indicated in the Basic Schedule provided always that, there is the insured benefit for Surgical Bonus in the Policy Schedule of Benefits. 2. In basic Plan, the amount of the insured Surgeon Fee (listed in the Schedule of Benefits) shall be the limit payable in aggregate for surgical procedure for all operations arising out of one disability. 3. If an operation be performed which is not listed in the schedule, the Company shall pay an amount which would be payable for a scheduled operation of equivalent gravity. 4. If more than one surgical procedure was performed through the same incision, the Company shall pay only for the surgical procedure in respect of which the largest amount becomes payable. 5. If more than one surgical procedure was performed at the same surgical session through different incisions the Company will pay, subject to the provisions of Note 4 above, as follows:- a) 100% fees for the procedure for which the greatest fee is payable. b) 50% for the next most costly procedure. c) 25% for the third and subsequent most costly procedure.
Appears in 4 contracts
Sources: Group Hospital & Surgical Insurance Policy, Group Hospital & Surgical Insurance Policy, Group Health Insurance Policy
SUITS AGAINST THIRD PARTIES. Nothing in this Policy shall render the Company liable or be responsible or to be added as a party in any way whatsoever to any suit for damages which may be instituted by the Policyholder or an Insured nominated under this Policy against any provider of Medical or Dental Services or Treatments, wherein such may sue the same for reasons of neglect, malpractice or other causes arising from his/her acts or omissions in the treatment or examination of any Insured under the terms of this Policy Notes:-
1. The following surgical schedule indicate the percentage payable on the insured benefit for Surgeon Fee stated in the Policy Schedule of Benefits for the corresponding surgical operation. Where shown, the Bonus payment on major surgery will be payable in addition to the percentage indicated in the Basic Schedule provided always that, there is the insured benefit for Surgical Bonus in the Policy Schedule of Benefits.
2. In basic Plan, the amount of the insured Surgeon Fee (listed in the Schedule of Benefits) shall be the limit payable in aggregate for surgical procedure for all operations arising out of one disability.
3. If an operation be performed which is not listed in the schedule, the Company shall pay an amount which would be payable for a scheduled operation of equivalent gravity.
4. If more than one surgical procedure was performed through the same incision, the Company shall pay only for the surgical procedure in respect of which the largest amount becomes payable.
5. If more than one surgical procedure was performed at the same surgical session through different incisions the Company will pay, subject to the provisions of Note 4 above, as follows:-
a) 100% fees for the procedure for which the greatest fee is payable.
b) 50% for the next most costly procedure.
c) 25% for the third and subsequent most costly procedure.. Abdomen, exploratory laparotomy, Cyst or abscess, marsupialisation of…………………………... 94.00 - celiotomy………………………………………..................... 65.00 - Hepatorrhaphy – suture wound, simple……………………….. 92.00 - Peritoneum, abscess, drainage……………………………… 68.00 - Mouth & ▇▇▇▇▇▇, Glossectomy, partial, with unilateral Anus, Abscess, incision and drainage……………………… 14.00 - radical dissection………………………………………………. 100.00 40.00 Fistulectomy, subcutaneous…………………………………. 17.00 - total, with unilateral radical neck dissection………………… 100.00 65.00 Submuscular………………………………………………… 56.00 - Pancreas, Biopsy pancreas 92.00 Fissurectomy, with/without Excision lesion of pancreas…………………………………….. 100.00 10.00 sphincterotomy……………………………………………… 31.00 - Pancreatectomy, with pancreatico-jejunostomy……………… 100.00 40.00 Haemorrhoidectomy, external, complete…………………... 37.00 - ▇▇▇▇▇▇▇ type……………………………………………………. 100.00 120.00 internal and external, simple………………………………. 45.00 - Marsupialisation, cyst of pancreas…………………………….. 94.00 - Appendix, Abscess, incision and drainage……………….... 46.00 - Pharynx, Adenoid, Tonsils, Drainage, abscess, Appendectomy………………………………………………... 58.00 - peritonsillar…………………………………………………….. 3.50 - Cholecystectomy……………………………………………… 82.00 - retropharyngeal/parapharyngeal, intra oral………………… 15.00 - with open exploration of common duct…………………… 100.00 5.00 Tonsillectomy, with or without adenoidectomy, age 12 and Cholecystotomy or cholecystostomy………………………… 74.00 - over……………………………………………………………… 27.00 - Endoscopy, Anoscopy, with collection specimen................ 4.00 - Adenoidectomy…………………………………………………… 18.00 - Colonoscopy, beyond splenic flexure…………………….. 42.00 - Rectum, incision and drainage, deep supra levator/ with removal polyp………………………………………..... 71.00 - perirectal/retrorectal abscess………………………………… 31.00 - Esophagoscopy, with collection specimen…………………. 23.00 - Biopsy incisional, ano-rectal wall anal approach……………... 27.00 - with biopsy, one or more…………………………………… 25.00 - Proctectomy, complete, combined abdominoperineal............. 100.00 55.00 Esophagogastroscopy, with collection specimen………….. 27.00 - Proctoplasty, for prolapse mucous membrane……………….. 76.00 - with biopsy, one or more…………………………………… 29.00 - Protopexy for prolapse, with sigmoid resection………………. 100.00 40.00 Gastroscopy, with collection specimen……………………… 22.00 - Closure, rectovesical, rectourethral fistula, with Esophagus, Esophagotomy, cervical approach, Colostomy………………………………………………………. 100.00 45.00 with/without removal foreign body………………………… 83.00 - Stomach, Gastrotomy, with exploration or foreign body Esophagectomy, resection with gastric anastomosis…….. 100.00 90.00 removal…………………………………………………………. 78.00 - Diverticulectomy, esophagus or hypopharynx,cervical Pyloromyotomy………………………………………………… 64.00 - approach 85.00 - Local excision ulcer or tumor…………………………………. 94.00 - Esophagoplasty, with repair of tracheo-esophagal Total gastrectomy, with repair by intestinal transplant…….. 100.00 100.00 fistula…………………………………………………………. 100.00 25.00 Sub-total or hemigastrectomy, with vagotomy………………... 100.00 30.00 Intestines, Duodenotomy…………………………………….. 94.00 - Vagotomy and pyloroplasty, with or without gastrotomy……. 100.00 10.00 Enterotomy, with exploration/removal foreign body, Pyloroplasty………………………………………………………. 83.00 - small bowel………………………………………………...... 94.00 - Herniorrhaphy……………………………………………………. 35.00 - Excision, one or more lesions small/large bowel, Herniotomy……………………………………………………….. 60.00 - single enterotomy…………………………………………… 92.00 - Strangulated Hernia……………………………………………… 75.00 - Enterectomy, resection small intestines……………………. 100.00 10.00 Colectomy, partial, with anastomosis……………………..... 100.00 20.00 Amputation And Disarticulations with colostomy………………………………………………. 100.00 65.00 Arms, through humerus, with implant…………………………. 80.00 - Tube enterostomy or cecostomy……………………………. 65.00 - Ankle, disarticulation/amputation, through malleoli, tibia Ileostomy…………………………………………………..... 94.00 - and fibula……………………………………………………….. 73.00 - Liver, needle biopsy, percutaneous………………………… 9.00 - Finger or thumb, amputation at any joint, single, wedge biopsy……………………………………………….. 65.00 - including neurectomy…………………………………………. 25.00 - Foot, amputation, mid-tarsal or transmetatarsal………….. 67.00 - KNEE: closed, manipulative reduction, Forearm, through radius and ulna………………………….. 60.00 - with anaesthesia……………………………………………… 20.00 - Hand, transmetacarpal………………………………………. 60.00 - close or open, open reduction………………………………. 100.00 - 100.00 100.00 reduction, with anaesthesia…………………………………. 17.00 - closed or open reduction, with/without patellectomy……… 80.00 - 80.00 - SHOULDER: sternoclavicular, manipulative reduction…….. 18.00 - Hip, interpelviabdominal amputation……………………….. 100.00 230.00 KNEE CAP: closed manipulative disarticulation ………………………………………………. Leg through tibia and fibula, with immediate fitting Technique…………………………………………………… Disarticulation at knee……………………………………….. Toe, amputation, metatarsophalangeal joint………………. Wrist, amputation…………………………………………….. Skull, ▇▇▇▇ holes, not followed by other surgery……………. ▇▇▇▇ hole or trephine for drainage intracranial abscess or cyst………………………………………………………… craniectomy or craniotomy, exploratory………………….. supratentorial infratentorial………………………………… exploration or orbit or decompression, unilateral……….. closed or open, acute or chronic, open reduction/ repair…………………………………………………………. 67.00 - Shoulder, amputation, inter thoracoscapular………………. 100.00 100.00 Disarticulation…………………………………………………. 100.00 45.00 Thigh, amputation through femur, any level……………….. 87.00 - TOES: tarsal bone, closed, manipulative, 83.00 - with anaesthesia……………………………………………… 13.00 - 20.00 - closed or open, open reduction…………………………….. 40.00 - 53.00 - astragalo-tarsal joint, closed, manipulative, without anaesthesia ……………………………………….. 6.50 - with anaesthesia……………………………………………. 17.00 - 48.00 - open, uncomplicated, manipulative………………………… 23.00 - closed or open, open reduction…………………………….. 53.00 - 100.00 35.00 Tarso-metatarsal, closed 100.00 95.00 manipulative, with anaesthesia …………………………… 13.00 - 100.00 130.00 with percutaneous skeletal fixation……………………….. 20.00 - 100.00 45.00 closed or open, open reduction……………………………. 40.00 - 100.00 10.00 metatarsophalangeal, closed, manipulative 100.00 35.00 with anaesthesia ……………………………………………. 9.50 - 100.00 55.00 closed or open, open reduction……………………………. 27.00 - 100.00 35.00 Interphalangeal joint, closed, manipulative 100.00 70.00 with anaesthesia ……………………………………………. 5.00 - closed or open, open reduction……………………………. 16.00 - except meningioma………………………………………… 100.00 100.00 meningioma ………………………………………………… 100.00 130.00 Brain abscess, excision of ………………………………….. 100.00 100.00 Cyst, excision of fenestration, supratentorial……………… 100.00 100.00 Brain tumor, infratentorial or posterior fossa………………. 100.00 140.00 meningioma, infratentorial or posterior fossa……………. 100.00 150.00 Lobectomy, partial or total…………………………………… 100.00 120.00 Hemispherectomy……………………………………………. 100.00 170.00 Craniectomy for crainiostenosis, multiple sutures………… 100.00 70.00 Foreign body, excision of from brain……………………….. 100.00 95.00 SPINE: spinal puncture, lumbar, diagnostic………………. 4.00 - for decompression ………………………………………… 6.00 - WRIST: radio-carpal or intercarpal, closed, manipulative reduction 17.00 - closed or open, open reduction 50.00 - Distal radio-ulnar, closed, manipulative 20.00 - Removal of kuntscher nail……………………………………… 8.50 Ear - Myringotomy by needle,with/without spiration/eustachian inflation………………………………………………………… 9.50 - with opening microscope, office…………………………….. 9.00 - in surgical suite 23.00 - aminectomy for exploration intraspinal canal, one or Transmastoid antrotomy 64.00 - two segments cervical or thoracic……………………….. 100.00 80.00 Mastoidectomy modified radical or radical, unilateral………. 100.00 30.00 lumbar……………………………………………………….. 100.00 60.00 Excision, aural polyp……………………………………………. 5.50 - for decompression spinal cord and/or Tympanoplasty, with mastoidectomy ………………………… 100.00 55.00 Cauda equina, one or two segments, cervical with ossicular chain reconstruction …………………………. 100.00 75.00 thoracic…………………………………………………….. 100.00 75.00 Fenestration, unilateral ………………………………………… 100.00 50.00 lumbar……………………………………………………….. 100.00 45.00 Stapes mobilisation……………………………………………… 77.00 - aminotomy, one interspace, for herniated disc and/or Excision aural polyp 5.50 - decompression root nerve, cervical………………………. 100.00 45.00 Myringoplasty…………………………………………………….. 88.00 - bilateral………………………………………………………. 100.00 80.00 lumbar……………………………………………………….. 100.00 35.00 Endocrine System aminectomy, for herniated disc, thoracic, posterior THYROID: Thyro-glossal cyst, incision and drainage………. 4.00 - approach…………………………………………………….. 100.00 80.00 biopsy, needle…………………………………………………. 8.00 - thoracic………………………………………………………. 100.00 95.00 isthmus 62.00 - Tympanostomy (requires insertion of ventilating tube) L L Discectomy, single interspace, cervical……………………. 100.00 40.00 cyst or adenoma, small, excision of, or transection of lumbar……………………………………………………….. 100.00 70.00 Lobectomy, total, unilateral, with contralateral subtotal lobectomy……………………………………………………… 92.00 - Dislocations Thyroidectomy, total or complete……………………………… 97.00 - ANKLE, closed, manipulative reduction total or sub-total with radical neck resection……………….. 100.00 85.00 with anaesthesia……………………………………………. 17.00 - closed or open, open reduction…………………………… 80.00 - Excision, fixation or repair by cutting operations Distal tibio-fibulor joint, closed or open reduction………. 53.00 - ANKLE: Achilles Tendon repair; primary……………………… 73.00 - ELBOW: closed, manipulative reduction lengthening or shortening of tendon, single 47.00 - with anaesthesia…………………………………………… 17.00 - ELBOW: Tendon lengthening, single…………………………. 40.00 - closed or open, open reduction………………………….. 67.00 - Flexorplasty……………………………………………………. 80.00 - FINGERS: Metacarpophalangeal, closed Arthroplasty, radical head, with implant 67.00 - requiring anaesthesia……………………………………… 17.00 - FEMUR, excision bone cyst/benign tumor…………………… 69.00 - open, uncomplicated, manipulative……………………… 20.00 - with autogenous graft (including obtaining graft)…………… 100.00 - closed or open, open reduction………………………….. 40.00 - HAND and FINGERS, excision/curettage bone cyst/benign HIP: traumatic dislocation, manipulative, tumors, metacarpal, with autogenous graft with anaesthesia…………………………………………… 32.00 - (includes obtaining graft)……………………………………. 54.00 - closed or open, with acetabular hip fixation…………….. 100.00 45.00 phalanx……………………………………………………….. 38.00 - JAW: temporo-mandibular, simple, closed with autogenous graft (includes obtaining graft) 50.00 - open reduction with interdental fixation…………………. 100.00 10.00 including graft 100.00 - L reduction…………………………………………………….. 12.00 - HIP: external oblique muscle transfer to greater trochanter, iliopsoas transfer to greater trochanter ………………….. 100.00 35.00 closed/open, open reduction, with/without skeletal arthroplasty with acetabuloplasty ………………………… 100.00 100.00 fixation…………………………………………………………. 67.00 - acetabular and proximal femoral prosthetic JAW: mandibular, closed, manipulative reduction with replacement……………………………………………….. 100.00 160.00 interdental fixation…………………………………………….. 53.00 - osteotomy, iliac or acetabular ……………………………. 100.00 35.00 open reduction with interdental fixation…………………….. 100.00 10.00 arthrodesis, hip joint, with subtrochanteric osteotomy…. 100.00 110.00 KNEE CAP: open reduction……………………………………. 27.00 - HUMERUS: excision/curettage bone cyst/benign tumor…. 63.00 - RADIUS: shaft, closed, manipulative KNEE: suture infrapatellar tendon, primary……………….. 67.00 - reduction-age 12 and over………………………………….. 29.00 - lengthening hamstring tendon, multiple one leg………… 53.00 - closed/open, open reduction, with skeletal fixation, repair, primary, torn/severed collateral ligament with or age 12 and over…………………………………………….. 67.00 - without meniscectomy……………………………………. 93.00 - RIBS: simple, 1 lib………………………………………………. 10.00 - collateral and cruciate ligaments…………………………. 100.00 20.00 SCAPULA: closed manipulative reduction…………………… 19.00 - PELVIS: excision bone cyst/benign tumor, superficial close/open: juxta-articular, open reduction with/without pelvis, with or without graft………………………………… 33.00 - skeletal fixation……………………………………………… 80.00 - SPINE: vertebral process, one/more, manipulative EYEBALL: evisceration ocular contents, and fusion, posterior, approach, with local………………. 100.00 85.00 with implant………………………………………………….. 62.00 - anterior approach with iliac or other bone graft…………… 100.00 100.00 exenteration of orbit, with temporalis muscle transfer….. 100.00 35.00 TIBIA and FIBULA: shafts closed, manipulative removal foreign body, conjunctival, superficial………….. 1.00 - with/without external pinning………………………………… 58.00 - embedded, subconjunctival or scleral………………….. 8.00 - Closed/open, open reduction, with/without skeletal corneal, with slit lamp…………………………………… 4.00 - fixation, age 12 and over……………………………………. 97.00 - EXTRAOCULAR MUSCLE, repair wound……………….. 22.00 - ULNA & RADIUS: shaft, closed, manipulative reduction CORNEA: excision of lesion…………………………………. 45.00 - age 12 and over………………………………………………. 40.00 - excision or transposition of pterygium …………………… 34.00 - closed/open, open reduction, with skeletal fixation: SCLERA: fistulisation for glaucoma, trephine with age 12 and over…………………………………………….. 100.00 - iridectomy……………………………………………………. 78.00 - WRIST: ▇▇▇▇▇▇ and ▇▇▇▇▇ type: repair scleral staphyloma, with graft……………………… 100.00 35.00 closed manipulative reduction IRIS: Iridotomy, stab incision………………………………… 28.00 - age 12 and over…………………………………………….. 27.00 - Iridotomy, with cyclotomy …………………………………. 100.00 25.00 Closed, complex, with external skeletal fixation/ LENS: removal after cataract or membranous cataract….. 78.00 - percutaneous pinning………………………………………. 50.00 - removal lens material, aspiration technique……………... 100.00 10.00 expression of cataract, linear……………………………… 100.00 10.00 Genital Systems RETINA: repair retinal detachment 100.00 25.00 with vitrectomy, with/without air tamponade…………….. 100.00 75.00 Male lacrimal sac………………………………………………… 8.00 - radical………………………………………………………… 100.00 65.00 reduction with/without skeletal fixation…………….......... 60.00 - prostatectomy, external drainage of abscess ELBOW: comminuted, closed, manipulative reduction….. 53.00 - complicated…………………………………………………… 80.00 - closed or open, or open reduction,with/without skeletal prostatectomy, sub-total or tota
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