Schedule 9

Regulation 8 does not apply to an insured person’s first insurance period.(2) The premium for the insured person’s first insurance period is equal to the pro-rated amount of the premium under the MediShield Scheme for the period of the last policy year of the insured person’s pre-existing MediShield cover falling on or after 1 November 2015 (called the unexpired period of the insured person’s pre-existing MediShield cover).(3) Any premium paid for the insured person’s insurance cover under the MediShield Scheme in respect of the unexpired period of the insured person’s pre-existing MediShield cover is to be credited towards the payment of that premium for the insured person’s first insurance period.Claim limits3.—

This paragraph does not apply to an insured person’s cross implementation claim.(2) Sub-paragraph (3) does not apply to an insured person’s cross insurance period claim with an initial insurance period which is the insured person’s first insurance period to which regulation 20(1)(a) applies, except as provided in regulation 14(3)(a).(3) Instead of applying regulations 13(1) (relating to a person’s insurance period limit) and 14(2) (relating to the excess limit for a cross insurance period claim), the amount of a claim under an insured person’s MediShield Life cover that may be paid in respect of the first insurance period of the person’s insurance cover is an amount not exceeding the excess limit for the claim (called the current claim) determined in accordance with the following formula:100,000 − X,where Xis the total amount of other claims (in dollars) —

received before the Board received the current claim; and

paid under —

the person’s MediShield Life cover in respect of the first insurance period of the person’s MediShield Life cover; or

the person’s pre-existing MediShield cover in respect of —

the last policy year of the pre-existing MediShield cover; or

the cross implementation period of a cross implementation claim made under the person’s pre-existing MediShield cover.(4) Instead of applying regulation 13(3), but subject to sub-paragraph (3), an insured person is entitled to claim under the Scheme, in respect of approved medical treatment or services received by the insured person in an approved medical institution as an in-patient or as day surgical treatment with an admission date in the insured person’s first insurance period (called the current claim), an amount determined by applying one of the following formulae:

if A is not more than $5,000, the formula is —[(A − B) × 0.9] − C;

if A is more than $5,000 but not more than $10,000, the formula is —[($5,000 − B) × 0.9] + [(A − $5,000) × 0.95] − C;

if A is more than $10,000, the formula is —[($5,000 – B) × 0.9] + ($5,000 × 0.95) + [(A − $10,000) × 0.97] − C,where Ais the sum of —

the relevant amount for the approved medical treatment or services to which the current claim relates; and

the relevant amount for all other approved medical treatment or services —

with an admission date during the cross implementation period of person’s current claim; and

in respect of which a claim under the the person’s pre-existing MediShield cover or MediShield Life cover was received by the Board before the current claim was received; Bis the lower of the following amounts:

A;

the insured person’s contribution for the approved medical treatment or services to which the current claim relates; andCis the sum of all claims paid for the other approved medical treatment or services referred to in sub-paragraph (b) of the definition of A.(5) The assured amount for any approved medical treatment or services under item 2 of the Sixth Schedule during the first insurance period of an insured person’s MediShield Life cover, with an admission date during that period, is $100 per day, up to the number of days determined in accordance with the following formula:35 − D,where Dis the number of days paid in respect of claims under the person’s pre-existing MediShield cover —

in relation to medical treatment, with an admission date in the last policy year of the person’s pre-existing MediShield cover, under item 2 of Part VI of the Third Schedule to the revoked MediShield Regulations; and

received by the Board before the person’s current claim was received. (6) In sub-paragraph (4) —“assured amount”, in relation to each item of approved medical treatment or services —

in respect of which a claim is made under an insured person’s MediShield Life cover, means the amount specified in the Sixth Schedule in respect of that item of approved medical treatment or services, with the modifications specified in sub-paragraph (5), if applicable; or

in respect of which a claim is made under an insured person’s pre-existing MediShield cover, means the amount specified in the second column of Part VI of the Third Schedule to the revoked MediShield Regulations in respect of that item of medical treatment;“cross implementation period”, in relation to an insured person’s cross implementation claim, means the last policy year of the insured person’s pre-existing MediShield cover and the insured person’s first insurance period’s MediShield Life cover;“relevant amount” —

in relation to approved medical treatment or services in respect of which a claim is made under an insured person’s MediShield Life cover, means the lower of the following:

the amount determined in accordance with regulation 13(7)(a);

the total of the assured amounts of the approved medical treatment or services; or

in relation to approved medical treatment or services in respect of which a claim is made under an insured person’s pre-existing MediShield cover, means the lower of the following:

the amount determined in accordance with regulation 10(9) of the revoked MediShield Regulations;

the total of the assured amounts of the approved medical treatment or services.Insured person’s contribution