Understanding Your Individual Plan

Colina’s Individual Medical (SHAPE ABCD) plans are managed care major medical plans which provide essential health benefits like emergency services, primary & specialist care, surgical services, hospitalization, overseas care, organ transplants, preventive care, prescription medication, maternity and newborn care and much more. We have Individual Medical plan options with varying levels of benefits to suit your needs and budget.

Managed care plans are a type of health insurance.
One of the goals of managed care is to reduce cost and control the cost of health care for insureds by forming provider networks and contracting with providers and medical facilities to provide care for insureds at reduced costs. Preventative care is a feature of managed care plans.

Your premium due date
Timely payment of premiums is important to ensure your policy remains inforce and that you are able to access medical care. Premiums are due and payable on the 1st day of each month.

Premium payment options
We offer a range of premium payment options including:
Over-the-counter payments at your nearest Colina location.
Salary deduction via your employer
Posted Dated Cheques
Pre-Authorized Cheques/Direct Debit
Online banking

Premium arrears & suspension of benefits
Your policy will be in arrears whenever the premiums are not paid by the due date. If your policy is more than 30 days in arrears, your benefits will be suspended and you will not be able to access medical services through your health plan. It’s your responsibility to ensure that your premium payments are up to date.

Policy Termination
Colina has the right to terminate your policy for the following reasons:
If premiums are more than 90 days in arrears, and provided prior written notice was given in advance of the termination date.
When the maximum benefit amount under your policy has been paid on behalf of a covered person.
Misrepresentation on the Application for Insurance or fraud in obtaining coverage.

Changes to your premium
Your premium can change from time to time. When this occurs, we will write to the Policyholder to let them know what the new premium will be. It will be the policyholder’s responsibility to ensure that the new premium is submitted, to avoid suspension of benefits or policy termination. Policyholders who pay their premiums via any form of standing payment instructions such as Salary Deduction or Post Dated Cheque (PDC) will be required to meet with their sales representative or visit any Colina location to complete a plan adjustment form.

Your health insurance ID card
All covered persons under your plan will receive an ID card with their own Member ID. Your Member ID is on the card which identifies you as a covered person. You are required to present this card whenever you visit a provider to receive medical services. Confirm that your name and date of birth on the card are correct and contact our Customer Relations Unit about any discrepancies or to request a replacement card in the event it is lost or stolen.

Waiting periods
It’s the period of time specified in a health insurance policy which must pass before some or all of your health care coverage can begin. The waiting periods under your health insurance plan are as follows:
No benefits will be payable for expenses incurred by a covered person within the first 90 days after the effective date of the policy except for: Services rendered for infections; and
Services rendered for accidents and/or emergencies.

No benefits will be payable for pre-existing conditions within the first 12 months after the effective date of the policy.
No benefits will be paid for pregnancy, complications of pregnancy or pregnancy-related conditions if conception occurs within 12 months of the effective date of the policy.

Limitations and Exclusions
Your plan does not provide coverage for all health care expenses and includes exclusions and limitations. These exclusions and limitations are outlined in your Policy Contract. Read your Policy Contract carefully to determine which health care services are covered benefits and to what extent.

Choosing a Medical Provider

Healthcare Providers within The Bahamas
Colina has an extensive local provider network. When accessing medical care, we strongly encourage you to choose a ‘Participating Provider’ from our list of network providers in your provider booklet or on our website at www.colina.com in order to minimize your out-of- pocket costs. You may also contact our in-house Medical Unit at 396-5100 who will be happy to assist you with coordinating your care. If you choose to receive medical care from a ‘Non-Participating Provider’ Colina will only pay 50% of Usual, Customary, and Reasonable Charges (URC) and you will be responsible for the balance.

Healthcare Providers outside The Bahamas
Colina also has an extensive overseas provider network. Prior to travelling overseas to obtain medical care, you will be required to contact our in-house Medical Unit at 396-5100 who will coordinate your care through our overseas Third Party Administrator (TPA), Sanus Health Corporation. If you choose to receive medical care from a ‘Non-Participating Provider’, Colina will only pay 50% of Usual, Customary, and Reasonable Charges (URC) and you will be responsible for the balance.

Case Management & Coordination of Care
Case management services are provided by Colina’s in-house Medical Unit and our overseas TPA Sanus Health Corporation, which comprises a number of certified Registered Nurses and physicians with specialized training. These experts use their clinical experience to evaluate the appropriateness and cost-effectiveness of medical care provided to our insureds, while in hospital and are able to coordinate all aspects of your care and provide guidance when you need it the most.

What to do in the event of a local medical emergency
In the event of a medical emergency, call 911 or go to the nearest private hospital emergency room. You will be required to make payment as stipulated in your Schedule of Benefits and according to the classification of the care administered. A referral is not required for emergency care. The Pre-Certification Program requires that a covered person, or someone on his behalf, contact the Company as soon as possible, but no later than 48 hours after a weekday admission, or within 72 hours if the admission is on a weekend or legal holiday, for an Emergency confinement to hospital.

Limited or non-covered services
Like most major medical expense plans, your Individual Medical plan includes exclusions and limitations. An exclusion states that under certain circumstances benefits will not be paid; a limitation states that only limited benefits will be paid. Your policy contract outlines those medical expenses not covered under your policy or with limited benefits.

Treatment needed as a result of someone else’s fault
Your policy contract contains a Subrogation clause which allows Colina to recover the cost of your medical treatment as a result of a negligent third party e.g. a motor vehicle accident in which you are a victim. Colina will pay your medical expenses upfront and then go after the negligent third party on your behalf.

Managing Your Plan
Adding or removing dependents
As your life situation changes you may need to add or remove members on or from your health plan, respectively. Only the policyholder or authorized person can add or remove persons.
The following is a list of eligible persons who can be added to your health plan:
A Spouse
Each unmarried child under 19 years of ages
Natural child;
Legally adopted child;
Child under legal guardianship; and
Stepchild
Each unmarried child between the ages of 19 and 25, provided the child is a full-time student in an accredited educational institution, and is not employed on a full-time basis.
A mentally retarded or physically handicapped child

Adding a newborn to your health plan
A new-born child may be added to an existing health plan and become eligible for coverage with effect from his or her date of birth, provided the enrollment application is completed and submitted to the Company within (31) days of his or her birth, accompanied by the 1st month premium. We strongly recommend that you add your new-born dependent child as soon as possible to prevent any delays in receiving benefits.

Requirements for your dependent(s) ages 19 – 25
You will be required to provide proof of full-time student status twice a year for your dependent(s) ages 19 – 25, no later than January 31st to verify coverage for the Spring Semester, and no later than September 30th for the Fall Semester.

Auto-conversion of dependent coverage
Your dependent child, upon attaining age 19 and who is not a full-time student can make application to convert to his/her own Individual Medical policy without evidence of insurability. Application must be submitted along with the first month’s premium, within 30 days of terminating of coverage. For more information about this feature, contact your sales representative or our Customer Relations Unit.

Upgrading or downgrading your existing health plan
Policyholders of Shape C or D, are permitted to upgrade to a Shape B or C plan by meeting the necessary medical underwriting requirements and paying the applicable policy administration fee. Any upgrade to a Shape A plan will be considered a new policy subject to full medical underwriting requirements, payment of the applicable policy administration fee, and waiting periods. Policyholders of Shape A, B, or C are also permitted to downgrade to Shape B, C, or D plan. Medical underwriting, waiting periods and policy administration fee do not apply.

Change of beneficiary
As your personal circumstances change, you may wish to revisit your beneficiary designation. For information concerning a change of beneficiary, contact your sales representative or our Customer Relations Unit.

Additional Coverage

Preventative Care
All Colina health plans offer an annual capped preventative care benefit for recommended routine check-ups and screenings to help you avoid getting sick and improve your health. Charges within this capped benefit are at no out-of-pocket cost to you. Any expenses above capped benefits will be the responsibility of the Policyholder. See your Schedule of Benefits for more details about this benefit.

Life & Accidental Death & Dismemberment Insurance
A life insurance benefit is available under this policy to the Policyholder and to their eligible dependents. Accidental Death & Dismemberment benefits only apply to eligible Policyholders. Benefits will be payable as stated in the Schedule of Benefits and Policy Contract to the individual(s) designated in writing as beneficiary(ies) of the Policyholder’s Life Insurance benefits.

How to file a claim
Choosing a “Participating Provider” from our provider networks eliminates the need for you to file a claim, for the most part. However, if you choose to receive care from a “Non-Participating Provider”, you will have to pay the provider in full for services and subsequently file a claim with us for reimbursement. We aim to settle claims within 3 – 5 business days.
To file a claim for reimbursement, simply follow these steps:

Have your physician or the medical facility complete the claim form and ensure that the following areas are completed.

Patient Name
Date(s) of Service
Type of Service(s)
Diagnosis Codes
Procedure Codes
Amount Paid for the Service
Total Charges for the Service
Only original documents will be accepted for processing
Under no circumstances should liquid paper be used on a claim form
Changes made to the form must be crossed out and initialled.
Payment receipts should be submitted along with your claim

All claims must be submitted within six (6) months from the date of service. Claims submitted outside of this time frame will be denied for untimely filing.

Pre-certification
Procedures or services requiring pre-certification or pre-authorization from the Company, prior to services being rendered, are outlined in detail in your Policy Contract under the Pre-Certification Program. A covered person must follow this program in order to receive full benefits payable under his/her policy. The provider office will typically obtain the required pre-certification, however, it is ultimately the covered person’s or policyholder’s responsibility to ensure that the pre-certification requirements have been met.

If you fail to obtain a referral, Colina will only pay 50% of Usual, Customary, and Reasonable Charges (URC) and you will be responsible for the balance.
You will be required to obtain pre-certification prior to using any of the following services:

Hospital Admission
Overseas Care
Surgical Services
Rehabilitation, Skilled Nursing Facility Confinements
Home Health Care
Diagnostic Procedures such as MRI, CAT Scans
Air Ambulance or Air Transportation
In-patient treatment
Behavioral Health Disorders such as drugs or alcohol addiction
Human Organ Transplants
Certain medications
Return/Repatriation of Deceased

Referrals
If you require specialist care locally or overseas, you must adhere to the following referral rules.
Referrals are valid for one (1) month from the date of issue.

Overseas Care
Colina must coordinate and approve all non-emergency overseas medical services. It is your responsibility to provide a letter of medical necessity and referral from a Specialist in The Bahamas to a Specialist overseas for a second opinion or for treatment not available locally. All overseas services require 72 hours pre-certification. Should you require emergency care while travelling, please access the nearest medical facility and/or contact Sanus Health Corporation, using the number on the back of your ID card. If you fail to obtain a referral, prior to obtaining non-emergency medical services overseas, Colina will only pay 50% of Usual, Customary, and Reasonable Charges (URC) and you will be responsible for the balance.

Paramedical Services
To obtain the following services, we require a referral from your attending physician, prior to obtaining medical services. If a referral is not obtained, prior to obtaining medical services, Colina will only pay 50% of Usual, Customary, and Reasonable Charges (URC).

The following services require you to have a referral:
Chiropractic Care
Physiotherapy
Speech Therapy
Masseurs Therapy

Explanation of Benefits
Each time Colina processes a claim submitted by you or your healthcare provider, we explain how we processed it in the form of an Explanation of Benefits (EOB).

The EOB is not a bill. It simply explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid and any balance you’re responsible for paying the provider. (We recommend you keep all of your EOBs)

Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider. If you observe any discrepancies between your EOB and the services you received of your statement from the provider, contact our Customer Relationship Unit immediately.

Changing your personal information
You are required to advise Colina when any of your personal details change such as your mailing address, telephone number(s) and email address, otherwise you might not receive important communications concerning your policy.

Relocating outside The Bahamas
As your policy is intended to cover insureds residing in The Bahamas, should you change country of residence and relocate outside of The Bahamas, except as a full-time student studying abroad, please notify us immediately.

Complaints
All grievances or complaints must be directed to the Customer Relations Unit by calling 396-5100
Or emailing them to [email protected]

We aim to resolve all grievances amicably and as quickly as possible. Should you wish to appeal a decision communicated by the Customer Relations Unit, you may do so through Colina’s formal complaints process by filing a written complaint addressed to Complaints Management Unit, Colina Insurance Limited or [email protected]

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