Government Employees (Health Insurance) (Benefits) Order 1997

Link to law: http://www.bermudalaws.bm/Laws/Annual%20Laws/1997/Statutory%20Instruments/Government%20Employees%20%28Health%20Insurance%29%20%28Benefits%29%20Order%201997.pdf

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Government Employees (Health Insurance) (Benefits) Order 1997
Title 9
Laws of Bermuda Item 16(b)

1989 Revision 1

BERMUDA STATUTORY INSTRUMENT

BR 32/1997

THE GOVERNMENT EMPLOYEES (HEALTH INSURANCE)
(BENEFITS) ORDER 1997

The Minister of Finance, in exercise of the power conferred upon
him by section 12 of the Government Employees (Health Insurance) Act
1986, and every other power vested in him, makes the following Order:—

Citation and commencement
1 This Order may be cited as the Government Employees (Health
Insurance) (Benefits) Order 1997 and shall come into operation on 6
June 1997.

Interpretation
2 (1) In this Order, except where the context otherwise requires—

"Bermuda Hospitals Board (Medical and Dental Charges) Order
1997" means the Order which—

(a) is prepared in accordance with section 13A of the
Bermuda Hospitals Board Act 1970; and

(b) prescribes the dollar values for items in the scale of fees.

"relevant date" has the meaning given to it in paragraph 5(3) of
Part I of the Schedule to this Order;

"scale of fees" means the scale of fees which—

(a) is prepared in accordance with section 13A of the
Bermuda Hospitals Board Act 1970; and

THE GOVERNMENT EMPLOYEES (HEALTH INSURANCE)
(BENEFITS) ORDER 1997

2 1989 Revision

(b) is used for assessing doctors' fees in respect of services
other than services attracting standard hospital benefit;

"standard hospital benefit" has the same meaning as it has in
section 1(1) of the Hospital Insurance Act 1970.

Benefits
3 The benefits to be enjoyed by each insured person in respect of
any one disability shall be as specified in the Schedule to this Order.

Revocation of BR 33/1986
4 The Government Employees (Health Insurance) (Benefits) Order
1986 is revoked.

SCHEDULE (paragraph 3)

BENEFITS IN RESPECT OF ANY ONE DISABILITY

PART I
STANDARD HOSPITAL BENEFIT

IN-PATIENT SERVICES
1 (1) (a) Accommodation and meals at the standard or public

ward rate;

(b) full nursing services;

(c) laboratory, radiological and diagnostic procedures,
including biopsies (except that surgeon's fees are not
included), together with the necessary reports, for the
purpose of maintaining health, preventing disease and
assisting in the diagnosis and treatment of any injury,
illness or disability;

(d) drugs, biological and related preparations which are
prescribed by an attending physician in accordance with
the hospital formulary and administered in the hospital;

(e) use of operating room, anaesthetic facilities and other
facilities required in operating procedure, including
necessary equipment and supplies;

(f) standard surgical supplies;

(g) use of radiotherapy facilities;

Title 9
Laws of Bermuda Item 16(b)

1989 Revision 3

(h) use of physiotherapy facilities;

(i) any service rendered by a person who is remunerated by
the hospital for that service;

(j) use of haemodialysis facilities;

(k) treatment for alcoholism (other than alcoholism causing
acute mental illness);

(l) use of ultrasound facilities;

(m)use of orthopaedic braces and artificial appliances;

(n) diabetic education and counselling but limited to one
education and one counselling programme; and

(o) hospice care in an establishment which the Committee
has approved.

(2) Special conditions applicable to maternity benefit, artificial
limbs and appliances and mental illness, alcohol and drug abuse are set
out below in paragraphs 4, 5 and 6 respectively.

LIMITATIONS OF IN-PATIENT BENEFIT
2 Subject to the Hospital Insurance (Portability) Regulations 1971
[title 18 item 9(e)], benefit in respect of in-patient treatment shall apply
without limit as to the duration of the period of confinement in the
hospital.

OUT-PATIENT SERVICES
3 (a) Pathological studies, X-ray and other diagnostic procedures

not obtainable or generally provided in a doctor's office as
prescribed by a physician, including biopsies (except that
the surgeon's fees are not included), together with the
necessary reports, for the purpose of assisting in the
diagnosis and treatment of an out-patient;

(b) the use of radiotherapy, occupational therapy and
physiotherapy facilities in the hospital when prescribed by a
physician;

(c) the hospital component of out-patient services necessary for
the initial treatment of accidental injuries suffered within 48
hours preceding the time of treatment or of acute illness and
the hospital component necessary to support operative or
diagnostic procedures performed by a registered medical
practitioner or under his direction; and

(d) local ambulance services in essential cases.

THE GOVERNMENT EMPLOYEES (HEALTH INSURANCE)
(BENEFITS) ORDER 1997

4 1989 Revision

MATERNITY BENEFIT
4 Maternity benefit will be payable for confinement as a result of
childbirth, pregnancy or miscarriage in accordance with the standard
hospital benefit provided that the insured person has been a government
employee for a period of 10 consecutive months immediately preceding
such confinement.

ARTIFICIAL LIMBS, ORTHOPAEDIC BRACES AND ARTIFICIAL
APPLIANCES
5 (1) The supply, maintenance, repair and renewal of artificial
limbs or any artificial appliance as defined in the Hospital Insurance
(Artificial Limbs and Appliances) Regulations 1971 [title 18 item 9(o)] will
be paid.

(2) The amount payable shall be calculated from the relevant
date and shall not exceed $10,000.

(3) In this paragraph, the "relevant date" means in relation to
an accident or injury giving rise to the need for an artificial limb or
artificial appliance, the date on which the accident or injury occurs, and
in relation to an illness, the date on which the surgical treatment for the
removal of the natural limb or implantation of the artificial appliance
occurs.

MENTAL ILLNESS, ALCOHOL & DRUG ABUSE
6 (1) (a) In-patient treatment (including the cost of

accommodation, meals, nursing and ancillary services)
of acute cases of mental illness, including those caused
by alcohol and drug abuse;

(b) out-patient treatment in respect of desensitisation
injections for cases of alcohol and drug abuse and other
psychotic conditions, electroconvulsive therapy and
electroencephalograms.

(2) In-patient treatment for any period in excess of 30 days in
any calendar year will not be paid.

PORTABILITY
7 Expenses incurred in a hospital outside Bermuda which has
been approved by the Committee for such purposes may be recovered,
subject to the terms of the Hospital Insurance (Portability) Regulations
1971 [title 18 item 9(e)], so however that—

Title 9
Laws of Bermuda Item 16(b)

1989 Revision 5

(a) in-patient treatment of any particular disability shall be
limited to expenses incurred over a period of not more
than 45 days during a twelve month period;

(b) the cover shall not include the cost of transportation to
or from a hospital approved under this sub-paragraph;
and

(c) the amount payable shall not exceed the amount which
would have been payable at the applicable public ward
per diem rate if the treatment had been received in the
general hospital in Bermuda.

SERVICES NOT INCLUDED IN STANDARD HOSPITAL BENEFIT
8 (a) Treatment of mental disorder, nervous disorders (other than

those with a defined pathological cause), chronic alcoholism
or drug addiction, except treatment prescribed under
paragraph 6 above;

(b) rest cures, sanitaria and custodial care including in-patient
treatment in the geriatric and rehabilitation ward in the
general hospital;

(c) cosmetic or plastic surgery unless such surgery is necessary
to correct traumatic injury;

(d) general health examination, dental work or treatment, dental
X-rays, extractions, fillings and general dental care except
dental surgery for the excision of impacted teeth or a tumor
or cyst or treatment of sound natural teeth damaged as a
result of an injury;

(e) treatment involving examination of the eye or ear for the
purpose of fitting eye glasses or hearing aids except where
such a treatment is necessitated by damage to the natural
eye or ear as a result of an injury;

(f) the provision of medication for the patient to take out of the
hospital;

(g) diagnostic services performed to satisfy the requirements of
third parties;

(h) visits solely for the administration of drugs, vaccines, sera or
biological products;

(i) transportation or travel other than local ambulance services;

THE GOVERNMENT EMPLOYEES (HEALTH INSURANCE)
(BENEFITS) ORDER 1997

6 1989 Revision

(j) treatment or advice given in the out-patient or emergency
department which would normally be provided in a doctor's
office; and

(k) treatment given or hospital facilities used which have not
been prescribed by a registered medical practitioner, unless
such treatment or use is certified as urgent and necessary by
a medical officer employed by the Board.

PART II
ADDITIONAL BENEFITS

HOSPITAL EXPENSES
1 For treatment in the emergency ward as an out-patient which
would normally be provided in a doctor's office, if it can be shown that
the insured person's doctor was not available or the condition which is
considered to be an emergency arose at a time when the doctor's office is
normally closed: expenses which the Committee shall approve as being
reasonable and customary.

SURGICAL EXPENSES
2 (1) For surgical operations in the hospital or in a doctor's clinic:
in accordance with the scale of fees and Bermuda Hospitals Board
(Medical and Dental Charges) Order 1997.

(2) Fees over and above those in the scale of fees shall be the
responsibility of the insured person.

ANAESTHETIST'S EXPENSES
3 (1) For anaesthetist's fees: in accordance with the scale of fees
and Bermuda Hospitals Board (Medical and Dental Charges) Order 1997.

(2) Fees over and above those in the scale of fees shall be the
responsibility of the insured person.

MEDICAL ATTENDANCE
4 (1) For attendance by a doctor in a doctor's clinic in respect of
emergency treatment immediately after an accident: expenses incurred
which the Committee shall approve as being reasonable and customary.

(2) For attendance by a doctor while confined in the hospital: in
accordance with the scale of fees and Bermuda Hospitals Board (Medical
and Dental Charges) Order 1997.

Title 9
Laws of Bermuda Item 16(b)

1989 Revision 7

(3) For attendance by a doctor otherwise than as described in
sub-paragraphs (1) and (2) above, the scale of fees will be used as
follows—

(a) while at home: to a maximum of 4 units per visit;

(b) in a doctor's clinic: to a maximum of 1.6 units per visit;

(c) in a doctor's clinic: to a maximum of 4 units in respect of
a first visit to a consultant if the insured person has
been referred to the consultant by a doctor;

(d) for psychiatric treatment: to a maximum of 3 units for a
half-hour and a maximum number of 25 visits per
calendar year:

Provided that, the insured person shall be responsible
for 20% of the charges incurred.

(4) Fees over and above those approved by the Committee or in
the scale of fees shall be the responsibility of the insured person.

DIAGNOSTIC PROCEDURES
5 For pathological studies, X-rays and other diagnostic procedures
which are obtainable in a doctor's clinic or in a private laboratory for the
purpose of assisting in diagnosis and treatment: expenses incurred
which the Committee shall approve as being reasonable and customary.

PREGNANCY (NON-HOSPITAL BENEFIT)
6 (1) In respect of medical attendance for any one pregnancy: in
accordance with the scale of fees and Bermuda Hospitals Board (Medical
and Dental Charges) Order 1997.

(2) Fees over and above those in the scale of fees shall be the
responsibility of the insured person.

DENTAL TREATMENT
7 (1) In case of injury to a sound natural tooth: expenses
incurred for immediate treatment in the dentist's clinic which the
Committee shall approve as being reasonable and customary.

(2) In case of further treatment prescribed by a dentist,
including the provision of dentures: expenses incurred to a maximum
determined by the Committee.

(3) In case of the excision of impacted teeth, a tumour or a
cyst: expenses incurred which the Committee shall approve in advance
as being reasonable and customary.

THE GOVERNMENT EMPLOYEES (HEALTH INSURANCE)
(BENEFITS) ORDER 1997

8 1989 Revision

BENEFIT FOR TREATMENT OVERSEAS
8 (1) The Committee may approve institutions for the purposes of
overseas medical treatment, consultation or technical investigation and
may adjust the admissible benefit payable under this paragraph where
such treatment, consultation or investigation is obtained at an
institution which it has not approved for such purposes.

(2) For health insurance cover for treatment, consultation or
technical investigation overseas, three categories of benefit shall apply,
that is to say—

Essential treatment, consultation or technical investigation

(a) Essential treatment, consultation or technical
investigation, for which there is no alternative in
Bermuda, which a medical or surgical specialist
practising in Bermuda has certified as essential and
urgent and immediately necessary for the health or
survival of the insured person or essential in the long-
term. The admissible benefits payable for this category
are as follows—

(i) medical, surgical and hospital expenses
incurred which the Committee has approved in
advance as being reasonable and customary;

(ii) travel expenses limited to a maximum
determined by the Committee;

(iii) expenses for essential ambulance plane services
limited to 80% of the cost thereof.

Funds will be made immediately available for essential
treatment, consultation or technical investigation in any
necessary case.

Optional treatment, consultation or technical investigation

(b) Optional treatment, consultation or technical
investigation which is not immediately necessary for the
condition of the insured person for which alternative
treatment may or may not be available in Bermuda but
for which it would be reasonable on medical advice for
the insured person to elect treatment, consultation or
technical investigation overseas. The admissible benefits
payable for this category are as follows—

Title 9
Laws of Bermuda Item 16(b)

1989 Revision 9

(i) the insured person will be responsible for all
charges incurred overseas and may claim
reimbursement for such charges at rates for
similar services provided in Bermuda plus 50%
of the difference between the charges incurred
overseas and the charges for similar services
provided in Bermuda:

Provided that, if the services were not available in
Bermuda the insured person may claim for medical
expenses which the Committee has approved as being
reasonable and customary; and

Provided that, if the services were provided as the result
of an emergency, the insured person may claim for
medical expenses which the Committee approves as
being reasonable and customary;

(ii) no claim may be made for travel or other
expenses.

Standard treatment, consultation or technical investigation

(c) Standard treatment, consultation or technical
investigation with or without medical advice which is
available in Bermuda and does not merit consideration
under category (a) or (b) above. The admissible benefits
payable for this category are as follows—

(i) the insured person may claim reimbursement
for charges incurred overseas at the rates for
similar services in Bermuda:

(ii) no claim may be made for travel or other
expenses.

PRESCRIPTION DRUGS
9 (1) Subject to an annual deduction of $25 in respect of each
insured person to a maximum of 80% of the balance thereof, expenses
for the cost of drugs prescribed for the treatment of an illness or
pathological condition and of accessory equipment prescribed by a
doctor which is necessary to determine the amount of the drugs required
to be administered or to administer the drugs will be paid.

(2) The insured person shall submit a claim for the
reimbursement of expenses incurred for the cost of prescription drugs to
the Committee by 30 April of the relevant year.

THE GOVERNMENT EMPLOYEES (HEALTH INSURANCE)
(BENEFITS) ORDER 1997

10 1989 Revision

(3) The Committee shall consider for its approval a claim for
the immediate reimbursement of expenses incurred for the cost of
prescription drugs if the insured person submits the claim by 30 April of
the relevant year and may approve the claim if it deems appropriate so to
do:

Provided that, the Committee may consider for its approval a
claim for the immediate reimbursement of expenses incurred for the cost
of prescription drugs where the insured person submits the claim to it
after 30 April of the relevant year and may approve the claim if it
determines that it is reasonable in the circumstances so to do.

(4) In this paragraph, "relevant year" means, whichever of the
following occurs first—

(a) the year in which the insured person incurred the
expenses for the cost of the prescription drugs; or

(b) the year next following the year in which the insured
person incurred the expenses incurred for the cost of the
prescription drugs.

PHYSIOTHERAPEUTIC AND MECHANICAL AIDS TO
REHABILITATION
10 Subject to an annual deduction of $25 in respect of each insured
person to a maximum of 80% of the balance thereof, expenses for the
cost of physiotherapeutic and mechanical aids to rehabilitation
prescribed by a doctor will be paid.

SPEECH THERAPY
11 Subject to a maximum period of 3 months for each prescription,
expenses which the Committee has approved in advance as being
reasonable and customary will be paid if the therapy is prescribed by a
doctor.

ASTHMA AND DIABETES COUNSELLING
12 Subject to a maximum of 80% of the expenses incurred,
expenses which the Committee has approved in advance as being
reasonable and customary will be paid if the counselling is prescribed by
a doctor.

EYE TREATMENT BENEFITS
13 (1) The insured person may, in accordance with sub-
paragraphs (2) and (3), claim a maximum of $150 for the cost of an
annual eye examination.

Title 9
Laws of Bermuda Item 16(b)

1989 Revision 11

(2) Where an eye examination results in—

(a) the initial prescription of lenses to an insured person; or

(b) a change in an existing prescription in respect of an
insured person,

the insured person may, subject to the maximum amount specified in
sub-paragraph (1), claim the cost of—

(c) the eye examination;

(d) the lenses; and

(e) the fitting of lenses.

(3) Where an annual eye examination does not result in the
prescription of lenses, an insured person may claim a maximum of $25
for the cost of that eye examination:

Provided that, if the insured person makes such a claim in any
year and a subsequent eye examination given to him during that same
year has the result set out in sub-paragraph 2(a) or (b), he shall only be
entitled to claim a maximum of $125 in respect of the cost of that
subsequent eye examination.