The plan is designed to give valuable financial assistance in meeting medical costs as a result of a covered accident or sickness. It is very important that you know the scope of the benefits, since you are responsible for any amount charged for medical care in excess of the benefits payable.
Here are some frequently asked questions about the plan. We have
also placed links below to brochures for more information. Feel free to
contact the credit union office for more information.
Under 65 yrs Leaflet
Over 65 yrs Leaflet
SPECIFICALLY ASKED QUESTIONS RELATED TO THE TRANSFER TO THE GENMED PLAN FOR CURRENT MEMBERS OF THE TEXMED PLAN
Information on the Change from Sagicor to GENMED
- Is there a waiting period before I can make claims?
Once you were a member of the TEXMED Plan before December 1st, 2022, you would not have a waiting period before you can make claims
- Can I still use my Caricare Card?
- Can I still make a Claim using Sagicor?
Members will be required to submit Sagicor claim forms instead for all claims made between 23rd November 2022 to 30th November 2022.
These forms can be obtained from our website Sagicor Claim Form for TEXMED or by visiting the Office.
- Does the GENMED Card work just like the Caricare Card>
If the provider is not on the network however, you would have to pay the full amount of the invoice and fill out a Beacon Insurance Claim Form.
- Who are the Providers in the Network?
Frequently
Asked Questions:
- I am healthy now, why do I need health insurance?
Health Insurance provides financial assistance against medical contingencies. If you apply for medical coverage after you get sick you are unlikely to get coverage. Regularly paying a set premium for health coverage assures that money will be available to defray the cost of everything from routine checkups to catastrophic medical bills. - What do I need to
present to join the plan?
A valid form of picture ID along with a copy of a recent utility bill to verify your identity and proof of address. Additionally, you would need to complete a Group Health Statement and an Enrollment Form. Additional requirements may be required upon review of the Group Health Statement. - Who is eligible for
coverage?
Active members of TEXTEL Credit Union, under the age of 65 years old. - If I come on the plan and then discontinue paying premiums during
the year, can I continue later on when I need the plan?
This is not advisable and you may be required to submit Evidence of Insurability before you are considered to rejoin the plan. - Is there any refund of premiums, if I don’t claim?
No, health insurance does not allow for refund of premiums or attract a no-claim bonus. - How long does it take to get reimbursement?
Holders of GENMED Cards, within the Network of Providers, will have their insurance benefit applied to the invoice immediately. Reimbursements done through the completion of claim forms would usually take 2 – 3 weeks from the time the claim forms are either uploaded onto the Online Portal or reach our office. However, there may be occasions where the Insurance Provider may need request more information. When more information is required, the processing time may be extended until all questions are answered or all requested information is provided. - What does Eligible Expenses mean?
Eligible expenses refer to costs incurred for medical care resulting from accident or illness. These must be administered/prescribed by a licensed medical practitioner and the services rendered must be related to the diagnosis. - What's
the difference between a deductible and coinsurance?
-Your deductible is the initial amount you must pay each year for covered health services before your insurer will start to reimburse.
-Covered charges incurred in the last three months of a calendar year, which were used to satisfy the Deductible, either in full or in part, may be carried over into the following year to assist in satisfying the Deductible.
-Co-insurance is a fixed percentage that you pay toward each service. Your plan carries an 80% - 20% co-insurance factor. - What is a waiting period?
A stated period after the beginning of coverage during which no benefits are paid. Your plan carries waiting periods for Dental (3 months), Vision (3 months), Preventative Care (3 months) and Maternity (10 months). This is applicable to both Members and Dependents. - What are pre-existing conditions and how do they impact coverage?
A pre-existing condition is a health condition (other than a pregnancy) or medical problem that was diagnosed or treated during a specified timeframe prior to the commencement of coverage. Your plan allows for a maximum of TT$1,000 for pre-existing conditions for the 1st 24 months. - What is Co-ordination of
Benefits and how does it work?
Even if you are insured under another Group Health Plan you are still eligible to enroll in this plan. Your claims would be handled under the Co-ordination of Benefits provision of the policy. The Primary Insurer would make the initial claim payment and the balance considered by the other insurer up to their plan limits. The order of payment is agreed among insurers.
- Claims for the member should be submitted to their existing Group Health Insurer first. It will then be forwarded to Sagicor.
- Claims for the spouse should be submitted to his/her Insurer first.
- Claims for dependent children should be submitted to the father’s Insurer first. - Who can be considered my dependents vs. a beneficiary?
A dependent is considered the spouse (married or common-law) and / or unmarried, unemployed children (inclusive of step-children or legally adopted children and / or foster children) up to 19 years of age or 23 years of age if they are attending school on a full time basis. Parents, siblings and/or extended family members are not considered dependents.
A beneficiary is the person or entity entitled to receive any claim amounts and other benefits upon the death of the member. It is advised that this person be 18 years and older and can include siblings, aunts, uncles and parents. - How
is Overseas Medical Treatment handled?
Medical expenses incurred for treatment abroad will be payable at the reasonable and customary levels prevailing in Trinidad and Tobago, unless it is proved to the satisfaction of the Company that such medical treatment is not available locally. This must be certified by two physicians, one of whom must be a specialist in the field of medicine to which the illness applies. Sagicor’s Medical Adviser must give approval of treatment prior to departure abroad. - How are claims handled?
Settlement of claims under this Plan is on a reimbursement basis, i.e. expenses will be initially borne by the Member and Sagicor will reimburse the insured Member up to the amounts recoverable under the plan when a properly documented claim is submitted on the prescribed claim form. Be sure to attach all related bills. Benefits may be assigned by the member for various services (hospital, surgeons, MRI, Dental & Vision), in which case Sagicor will pay direct to the provider the amount to which the Member may be entitled in respect of hospital and surgical expenses. What is Pre-Certification? Pre-Certification is a notification of anticipated or schedule medical services that is required in advance of the actual medical treatment. Before you actually receive treatment or incur the medical expenses, Sagicor, upon request by the Provider, issues a pre-approval letter stating whether the anticipated service is eligible for coverage and the level of charges that would be reimbursed from the health plan. Note: Any difference between the actual charges and the estimated cost as stated on the pre-certification will be for the insured’s account
What is required to attain Pre-Certification? A letter from the treating Physician or Medical facility with an itemization of the charges and the type of treatment/procedure recommended or scheduled must be sent to the Society, to be forwarded to Sagicor.
If I want to make a claim for a visit to a specialist, would I have needed a referral from a General Practitioner (GP) or could I have gone on my own? You need to have a referral from a GP in order to make a claim for a visit to a specialist. Ensure that you keep a copy of this referral to attach to the claim form. Should you visit a specialist without a referral, you would be reimbursed as if you visited a GP.
