Group Health Insurance FAQ
If you have a question that is not answered below, please contact us.
Group Health Insurance FAQs
Sponsor/Company/Employer
Health Insurance provides cover for the cost of medical expenses for medical investigations or treatment of an acute medical condition. This means that you would be covered if you have a disease, illness or injury that is likely to respond quickly to treatment which aims to return you to the state of health you were in immediately before suffering the disease, illness or injury, or which leads to your full recovery. Through the standard policy does not cover routine health check-ups, these can be purchased at an additional premium.
Health insurance can be provided to employees as part of a benefit package. We can provide a customisable solution that aligns with the needs of both your organisation and your employees which can be a valuable and appreciated employee benefit, contributing to overall job satisfaction and well-being.
We have three levels of cover available from which to choose from;
- The Vital Plan is a limited health insurance plan, with specific limits applicable to each benefit.
- The Key Plan is a comprehensive health insurance plan for treatment received in Malta.
- The International Plan is a worldwide comprehensive health insurance plan, cover in USA & Canada is limited to emergency treatment only.
In addition, we can consider offering optional add-ons to these health plans such as Dental Cover or Preventive Treatment Packages upon request.
Group health insurance operates on the principle of risk pooling, where the health insurance risks of the entire group are spread across all members. This can help offer lower premiums within the group for the insured members as opposed to individual policies for employees and their families.
A new health insurance group must have a minimum number of 5 members at inception. The members’ date of births are required to provide you with a quotation for our different health insurance options.
We will make the move of the current portfolio to GasanMamo as effortless as possible. We will ask you to provide us some information on your current insurance policy to assess the insurance risk involved and ensure we will provide you the same or better coverage you hold.
If you accept our proposal and depending on the type of cover you hold, we will need a list of the insured members and their details, and/or a copy of the current members’ latest membership certificate.
It is recommended that sponsors/employers contact us around 4 weeks prior to their renewal date.
Yes, we do allow group administrators to inform us on a monthly basis any group adjustments to include new employees and to terminate employees who are no longer part of the organisation. The premium or refund for such changes is calculated on a pro-rata basis from the date of inclusion/termination up until your group’s renewal date.
A pro-rata refund is not applicable in the following situations:
- Claims were made by the insured member (employee) on the policy.
- A reduction of 20% or more in the insured persons confirmed at inception or the last renewal of the group policy and/or
- The overall group’s claim loss ratio is 75% or more within the current insurance period and/or
- In the event of a bankruptcy, closure of company, liquidation, merger and acquisitions or relocating of operations overseas.
A group policy is an annual contract, and the entire policy cannot be cancelled for any reason throughout the insurance period.
Insured members can upgrade or downgrade their insurance cover at renewal of the group policy upon receipt of such instructions from the sponsor (employer/organisation). Depending on our agreement, a proposal form may be required from the insured member (employee) to upgrade cover.
Members cannot upgrade or downgrade their level of cover during the duration of the insurance period.
Depending on the agreement between us and the sponsor/employer, employees might be given the opportunity to include their dependents on the policy and benefit from the group’s preferential rates.
By dependants we refer to spouse/partner and biological or adopted children of the policyholder under the age of 18 or living at home.
Insured Members / employees
The policy covers for the cost of treatment/investigation for acute medical conditions. An acute medical condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return you to the state of health you were in immediately before suffering the disease, illness or injury, or which leads to your full recovery. Routine health check-ups are not covered under the policy unless you purchase additional cover for this.
Depending on your chosen level of cover, the policy covers for in-patient, day-patient and out-patient treatment/investigations such as:
- Hospital Accommodation
- Theatre Fees
- Surgeon & Anaesthetist Charges
- MRI, CT, PET Scans
- Oncology related charges
- State Hospital Cash Benefit
- General Practitioner & Specialist consultation charges
- Diagnostic tests such as ultrasounds, blood tests, x-rays etc..
- Treatment with a Psychiatrist
- Alternative Therapy
- Emergency Dental Care
- Home nursing
- Maternity Cash Benefit
Below please find some of the most common exclusions. For the full list of exclusions please refer to the policy wording.
- Pre-existing conditions – subject to the method of method of underwriting applicable to your policy
- Monitoring of chronic medical conditions
- Treatment undertaken by a specialist without a General Practitioner referral
- Cosmetic treatment
- Drugs & dressings (unless specified in your health plan)
- Routine health check-ups and preventive treatment
- Routine Pregnancy expenses
- dental treatment unless specified in your plan
- Appliances and medical aids such as hearing aids or crutches
- Sports injuries as specified in the terms and conditions
- Experimental treatment
- Congenital conditions
- Routine eye check-ups
- Any other specific exclusion or limitations shown in the policy wording
Claims can be submitted either by post or online.
Submit an online claim now by pressing here
Note that you can find your policy number on your policy schedule as this will be required to register the claim. Should you encounter any difficulties let us know and we can provide you with the policy number. We will also require your bank account details in section 3 of the claim form as settlement of your claim will be made directly into your bank account. If you have already provided us with your bank account details, you are not required to complete this section again unless you want to make a change to the account details.
Click here for more information on how to make a claim.
No, our policies do not have a waiting period before an insured can submit a claim except in the case of pregnancy complications or the maternity cash benefit where the mother must be insured for 12 months before she can claim.
A completed claim form must be submitted together with the original receipts, a copy of the results in case of diagnostic tests and a breakdown of charges incurred within 3 months from the date of treatment.
Always contact us before receiving any treatment as we would need to confirm your level of cover and whether direct settlement would apply. In such cases a detailed medical report is required from the specialist to confirm if direct settlement will apply. The insured can contact us on 21 345 123 or by sending an email to [email protected].
Should you need to be hospitalised urgently and have no time to contact us or the emergency happens outside of office hours please inform the hospital that you have an insurance policy with us so they will be able to contact us themselves. Please note that if the insured member is covered under the Vital Plan direct settlement does not apply and therefore, any expenses will need to be paid by them and all documentation is to be provided to us within 3 months from date of treatment.
Direct Settlement is when we settle your medical bills directly with participating hospitals and clinics in the case of in-patient or day-patient treatment for those insured under the Key Plan and International Plan.
Below is a list of Hospitals and Clinics in Malta which we recognize as participating hospitals/clinics. Always confirm with us before receiving any treatment as this list may be updated from time to time at our discretion.
- James Hospital in Sliema
- James Hospital in Zejtun
- Anne’s Clinic in Birkirkara
- Da Vinci Hospital in Birkirkara
The General Practitioner and/or Specialist must complete a claim form and you may claim the costs incurred by submitting the completed and signed claim form together with the original receipts, copy of the results in case of diagnostic tests and breakdown of charges incurred. A General Practitioner referral is required before consulting a specialist/therapist except in the case of a Gynaecologist, Ophthalmologist or Paediatrician. All diagnostic tests need to be referred by a General Practitioner or Specialist whilst MRI, CT or PET scans must be referred by a Specialist.
The policy includes limited cover as shown on your table of benefits for treatment received outside of Malta excluding USA & Canada. Direct Settlement is not applicable outside of Malta and therefore, the insured has to settle his/her medical bill with the hospital and claim within 3 months from the date of treatment by submitting a completed and signed claim form together with the original receipts, copy of the results in case of diagnostic tests and breakdown of charges incurred.
We will cover out-patient treatment up to what we consider to be fair and reasonable taking into account the complexity of the treatment involved, the degree of professional skill and other relevant factors up to the limits of your chosen plan. The following Fair & Reasonable fees apply for our-patient treatment.
- General Practitioner Charges – €25 per consultation
- GP consultation after hours/home visit –€35 per consultation
- Specialist Consultations – €70 per consultation
- Specialist home consultation – €90 per consultation
- Chiropractor, osteopaths, acupuncturists, homeopaths, physiotherapists and podiatrists – €40 per session up to 10 sessions per medical condition
- Paediatric Consultation – €50 per consultation
- Psychologist and psychotherapist Consultation – €50 per session
Fair & Reasonable fees apply for surgeon and anaesthetist charges in case of in-patient and day-patient treatment. These can be found on our website (https://www.gasanmamo.com/ ) and the list may be updated from time to time at our discretion.
Should we have all the information required in the claim form and all the necessary documents to process your claim, the claim will be settled within 15 – 20 working days. Payment can be paid directly into the policy holder’s bank account.