State Life, in collaboration with Government of Khyber Pakhtunkhwa, has taken initiative to launch Social Health Protection (SHP) to provide and promote social and micro health insurance scheme for the most deserving population of four districts of Khyber Pakhtunkhwa namely Kohat, Mardan, Malakand and Chitral. The scheme will target the most deprived segment of society and provide them access to the health facilities in a wide range of public and private hospitals. The proposed target market will tend to expand to include a wide range of society. The scheme aims to encourage:

• Utilization of health care facilities
• Provision of  quality health services
• Provision of cashless services to beneficiaries
• Awareness regarding financial risk due to health related perils

Under the scheme, the members will be covered for hospitalization, day care surgeries and maternity benefits, albeit under a prescribed limit. Along with the provision of these facilities, the quality of services will also be monitored for improvement. Features such as transportation cash grant on maternity will encourage the female population to utilize the health provider facilities and will ultimately result in improving the female and child survival rate.

More than 1 Million beneficiaries will be enrolled under the scheme to get the benefit of hospitalization.

Social Health Protection.

Under the scheme, there is no age limit and exclusion of pre-existing condition (except “Standard Exclusions”). The scheme will cover hospital services normally provided at the secondary level (up to DHQ hospital) but such services can be provided even at tertiary care hospitals.

Maternity and New Born coverage includes treatment taken in empanelled hospital/nursing homes arising from child birth including normal delivery / caesarean section and / or miscarriage or abortion induced by accident or other medical emergency subject to exclusion. New Born child will also be considered as part of household and covered under the scheme. For maternity cases, transportation charges of Rs.1,000/- per hospitalization will also be provided.

Exclusions.

The following treatment, items, conditions, activities and their related or consequential expenses are excluded from the Agreement and the Corporation shall not be liable for:

• Costs resulting from self-inflicted injury, attempted suicide, abuse of alcohol, drug addiction or sexual disorders and treatment of sexually transmitted diseases.

• Psychotic, mental or nervous disorders (including any neuroses and their physiological or psychosomatic manifestations) or sensual reassignment (whether or not for psychological reasons) .

• Treatment or investigation of fertility, infertility, sterilization or contraception and any complication relating thereto or hormone treatment and investigations.

• Participation in or training for any dangerous or hazardous sport, pastime or competition or any professional sport.

• Injuries as a results of an illegal act by the Insured Person.

• Injury or treatment resulting from war, riots, invasion, act of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, mutiny, civil commotion assuming the proportions of or amounting to a popular uprising, military uprising, insurrection, rebellion, military or usurped power or any act of any person acting on or on behalf of or in connection with any organization actively directed towards the overthrow or to the influencing of any government or ruling body by force, terrorism or violence.

• Ionizing radiation or contamination by radioactivity from any nuclear fuel or nuclear waste, from the process of nuclear fission or from any nuclear weapons material.

• Services or treatment in any spa, hydro clinic, sanatorium, nursing home or long term-care facility that is not a hospital.

• Acquired immune deficiency syndrome (AIDS related complex syndrome (ARCS) and all diseases caused by and /or related to HIV virus or any other Sexually Transmitted Disease (STDs).

• Experimental or unproven treatment.

• Dental examinations, D-rays, extraction, filling, general dental care / treatment and orthodontic treatment or oral surgery except as a result of emergency due to Accident.

• Cost of correction of refractive errors of the eye and procedures such as Radial Keratotomy and Excimer Laser.

• Routine medical examinations or check-ups including charges arising out of any hospital confinement or admission primarily for diagnostic purposes, routine eye or ear examinations, vaccinations, medical certificate, examination for employment or travel, spectacles, contact lenses, hearing aids and any treatment that is not considered medically necessary.

• Cosmetic or plastic surgery, unless it is re-constructive surgery necessitated by an injury that occurred during the period whilst the insured person was covered under this Contract and subject to the limits and sub-limits stated in the Benefits package.

• Any charges in respect of the donor for organ transplant claims.

• Cost of limbs or supporting equipment for revival or correction of the function(s) of body.

• Personal comfort items such as, charges for telephone, convenience items, meals or other items not medically necessary.