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xx天平卓越留学安心保个人医疗保障计划
（安盛天平）（备 - 医疗保险）【2017】（主）001 号
x保险合同由保险条款、保单、保险利益表、保险凭证、投保单、批单和补充协议组成。
谢谢您选择安盛天平卓越留学安心保个人医疗保障计划（以下简称“卓越留学安心保个人医疗保障计划”）。
请仔细阅读本保险合同，确保您理解其中的条款和条件，并将上述文件妥善保管。
如果阅读这些文件后有任何问题，请与安盛天平财产保险股份有限公司（以下简称“我们”）联系。
如果出现任何可能影响承保的情势变更，请立即通知我们。
关爱我们的客户。
我们承诺为我们的客户提供满意的服务，我们将：
• 认真倾听并了解您的需求；
• 针对您提出的各种问题，为您提供建议；
• 提供即时、高效的服务。
目录
x保险条款列明了卓越留学安心保个人医疗保障计划的特点和优势，包括保险计划的相关定义以及具体保障内容。
1.1 保险计划简介
卓越留学安心保个人医疗保障计划是一种承保国际学生及其配偶和（或）子女因突发疾病或意外事故而造成的医疗上合理且必须的费用的医疗保险。
1.2 个人服务
在安盛天平财产保险股份有限公司（“安盛天平”），我们始终铭记每一个理赔要求都代表一个需要我们帮助的人。如果您有任何不清楚的地方，请直接与安盛天平客户服务团队联系。
1.3 我们的客户服务团队
我们客户服务团队的工作是在任何可能的情况下为您和被保险人提供卓越留学安心保个人医疗保障计划条款和限额范围内的服务。在会员卡背面我们提供了客户服务团队的联系电话。
为保障您的利益，您的通话可能会被录音，以供下次查询或培训之用。
请您注意将会员卡放在一个安全、容易找到的地方。在呼叫我们的客户服务团队时，请拿出您的会员卡。会员卡上的信息将有助于我们尽快处理您的咨询。
1.4 保单内容
本文列出的保单条款，应与我们提供的补充文件一起阅读（如保险计划表、会员卡等）。我们尽量让这些内容清楚易懂，但是如您有任何不理解之处需进一步询问，请与我们联系。有关保障利益和（或）条款变动的决定不能口头作出，必须由我们书面确认。
本保险合同由保险条款、保单、保险计划表、保险凭证、投保单、批单和补充协议共同组成。请仔细阅读，特别是保险责任、除外责任和投保人、被保险人的义务条款。如果您或被保险人 有不理解之处，请咨询我们。
1.5 免费审阅期
从收到本保单文件之日开始，您将有三十（30）个工作日的免费审阅期（“犹豫期”）。保单文件在我们发出的三（3）天内视作收到。如果您觉得本保单不符合您的需求，可以在免费审阅期内向我们发出明确的书面通知并退回保单文件和会员卡，要求解除本保险合同。若在此期限内您没有提出任何索赔，我们将无息全额退还您已支付的保费，并对您解除合同之前的事故不承担任何责任。该规定不适用于续保。
2.1 投保资格
主被保险人必须同时符合以下标准（如果适用），投保人方可为其投保本保单下的保险：
a) 持有美国F-1 或J-1 签证的国际学生；
b) 在美国实际居住至少九十（90）天，且在保险生效日后作为国际学生上课至少三十一
（31）天；
c) 国籍是中华人民共和国（不含香港、澳门和台湾），或在中国大陆居住满一百八十五
（185）天的香港、澳门和台湾居民。；
d) 投保时应不超过六十五（65）周岁，续保时应不超过七十（70）周岁；
若被保险人配偶持有有效的美国 F-2 或 J-2 签证而且符合第 2.1 中 c)至 d)的相关标准，那么 有资格享受本保险合同下与主被保险人（即国际学生）一样的保障。配偶在本保障计划下的 被保险人资格在其本人成为另一留学生医疗保障计划的主被保险人（即国际学生）的同时失效。
若被保险人子女持有有效的美国F-2 或J-2 签证而且符合第 2.1 中 c)的相关标准，且需同时作为本保险合同被保险人的，主被保险人的子女至少出生满十五（15）天。
美国公民及拥有美国国籍的香港、澳门和台湾居民，均不能成为本保险合同的被保险人。
重要提示：
在您提交投保申请后，我们会书面确认保险范围。
本公司有权调查被保险人的身份状态和考勤记录，以验证其是否符合投保资格的要求。
某些情况下，是否可以成为被保险人将视不同国家的相关法律法规而定。我们可能由于国际、国家包括且不限于欧盟、英国、美利坚合众国、中华人民共和国（含香港、澳门和台湾）的 法律或联合国的法律法规或经济制裁的原因不能为您提供保障或服务。若我们发现任何潜在 风险，将尽快以书面形式通知您。
2.2 加保新生儿
您可在保单年度内将新生儿加保至国际学生的保单下，支付相关保费，若符合以下所有要求，则该新生儿从出生时开始享受保险：
a) 在新生儿出生十五（15）天后三十（30）天内提出加保到父母的保单中的书面申请，并付清保费；
b) 新生儿不是通过辅助生育而受孕的；
c) 提出加保申请时，新生儿已出院；
d) 新生儿不是收养的、或由代孕的；
e) 在新生儿出生时，父母已在本保单下连续承保至少三百六十五（365）天。
f) 父母必须提交可保证明。
若不符合第 2.2 中的任何一项要求，则我们有权根据核保规则决定是否在保单中加保新生儿。只有在我们书面确认承保后，方按我们所述条款承担保险责任。
3.1 定义
部分治疗和服务，投保人或被保险人应在接受治疗和服务前事先通知我们以取得授权，否则被保险人在承担免赔额、免赔比例和自付额的基础上，还必须额外承担以下可保费用的百分之五十（50%），即[（实际费用-免赔额）x 免赔比例-自付额（如适用）] x 50%。
3.2 事先授权的条件
强制性的事先授权是为了避免被保险人发生未预期的费用。事先授权申请需要同时满足以下条件：
a) 该治疗在您的保单中是可保的；
b) 该治疗是医疗上必要的；
c) 该治疗在合理且惯常的费用范围内；
d) 该治疗的费用在您的保险计划剩余的给付限额内。
3.3 事先授权的范围
事先授权对以下治疗和服务是强制性的：
a) 住院
b) 器官移植
c) 精神疾病治疗
d) 酒精和成瘾物品滥用的治疗
e) 艾滋病（AIDS）、人类免疫缺陷病毒（HIV）和性传播疾病（STD）
f) 门诊治疗
g) 职业治疗、物理治疗和言语障碍治疗
h) 受保孕妇的产科治疗
i) 避孕
j) 流产
k) 离院后康复治疗
l) 临终关怀和姑息治疗
m) 家庭护理/ 私人护理
n) 院际、校际、校内、体育俱乐部运动等导致的治疗
o) 使用耐用医疗设备进行的治疗
p) 紧急医疗运送和送返
q) 遗体送返
r) 陪同紧急运送和送返
(a）流产
自愿终止妊娠，大多数是在受孕后的前二十八（28）周内进行。该术语也与治疗性终止妊娠相关，即为了母亲或女性的健康且医疗上必要的妊娠终止。
(b）意外事故
任何超出被保险人控制、造成身体伤害的外来的、突发的、非疾病的、不可预见的客观事件。
(c）急症
被保险人遭受的疾病或伤害，必须立即接受紧急治疗才能使其恢复到生病或受伤之前的健康状态。
(d）投保单
由投保人为所有被保险人申请投保本保险而提及的申请，包括投保人填写的回答核保问题的表格。
(e）年龄
投保时被保险人的周岁年龄。
(f）辅助受孕
利用医学技术增加排卵期卵子的数量，或将一个精子与一个或多个卵子结合在一起，以增加受孕的机会。辅助受孕包括且不限于子宫腔内人工受精（IUI）、体外受精（IVF）、卵胞浆内单精子注射（ICSI）、或采用任何形式的治疗来诱导或增加排卵，包括代孕受孕。
(g）保险计划表
第 8 部分中适用于被保险人的保险计划的表格，列明了我们将给每个被保险人支付的最高保险金额。
(h）先天性疾病
在出生时存在的遗传性（包括遗传病）、物理或生物化学缺陷或疾病、畸形或异常，无论是否在出生时显现、诊断或已知的。
(i）免赔比例
您和（或）被保险人在扣除免赔额后需要支付的可保医疗费用中的比例。请查阅保险计划表中的免赔比例。
(j）自付额
您和（或）被保险人在扣除免赔额和免赔比例后需要自付的金额，只适用于门诊接受全科医生和（或）专科医生的治疗费用，除非保险计划表中另外注明。
(k）被保险人
包括本保单承保的主被保险人（即国际学生）和（或）附属被保险人，即主被保险人的合法配偶或子女。
(l）日间治疗
被保险人在医院或日间治疗部接受医疗监护但无需占用病床过夜（不含门诊治疗），获得医生开具的出院证明。日间治疗不包括任何形式的替代治疗、中医、针灸和顺势疗法。
(m）免赔额
可保医疗费用中必须由被保险人在保单年度内我们支付任何保险金前自己支付的部分。免赔额见保险计划表，适用于每次就诊。 当免赔额与自付额同时适用时，免赔额将先于自付额从可保医疗费用中扣除。
(n）牙科执业医师
我们承认的在世界卫生组织认可的牙科学校学习后取得初级牙科学位，然后在相关的法定牙科委员会或理事会注册并获得牙科治疗的执照的人（不包括投保人、被保险人或其业务伙伴或亲属）。
(o）附属被保险人
在投保人购买该保险或本保险续保时与主被保险人一起生活的（i）主被保险人（即国际学生）的合法配偶；或（ii）合法子女。本保单中的子女在其二十一（21）周岁生日后不得作为本保 单的被保险人（满 21 周岁的下一个保单年度起）。
但是，若该子女未婚且仍为教育机构的全日制学生，他/她的保险可续保至二十五（25）周岁。
(p）诊断
对出现的症状，为确诊对其属于承保范围内而需要的咨询和检查。
(q）可赔付的治疗
x保单承保的医疗上必要的治疗费用。为确定某项治疗或费用是否承保，请阅读本保单文件的所有部分，具体以本保单文件中列明的所有条款特别是保险责任条款和除外责任条款为准。
(r）急诊
突发的、未预料到的急性病症，严重危及生命，需要立即接受外科或内科诊治以避免死亡或永久性不可逆的完全功能丧失。
(s）批单
我们签发给投保人用于记录和确认对本保单合同的任何变动的补充文件。
(t）运送或送返
运送是指被保险人遭受意外伤害或急症，需要立即接受紧急治疗，却无法在当地寻求到恰当的医疗救助时，我们将其转运到最近的符合要求的另外一家具备必要医疗设施的医院；送返是指 i)被保险人经治疗后，我们将被保险人通过运输工具送返回其惯常居住国、或其护照签发国；ii)被保险人在其惯常居住国外身故，我们将被保险人的骨灰或遗体送返回其惯常居住国、或其护照签发国。服务内容包括我们指定的服务提供方在运送被保险人时提供的任何医疗上必要的治疗。
(u）医院
在其经营所在国注册的内科或外科医院或医疗机构，并同时达到以下要求：
• 主要工作是接收、护理和治疗生病、体弱或受伤的人（住院病人）；
• 提供每天二十四（24）小时护理服务；
• 随时有至少 1 名执业医师在岗；
•有完备的设施提供诊断和外科手术；
• 并非护理院、休养所、疗养院或类似机构，并非老年病房、药物滥用治疗机构，比如（包括且不限于）酒精、毒品康复训练或类似目的的机构。
(v）住院治疗
被保险人在医院病床上接受一个晚上或以上的可赔付治疗，不包括各种形式的替代治疗、中医、针灸和顺势疗法。
(w）主被保险人
持有美国F-1 或J-1 签证的国际学生，与投保人之间存在保险利益，具体见前述 2.1 条。
(x）重症监护室
医院内被指定为重症监护室的部分，专门为危重患者提供全天二十四（24）的治疗，配备医院中其他地方没有的特殊护理和医疗服务。
(y）终身
相关被保险人生存的期限，并非保单的期限。
(z）病症
x保单承保的任何疾病或伤害。
(aa）执业医师
我们承认的在医学院学习后取得初级西医和外科执业学位、然后在治疗所在地的相关发照机关获得西医执业执照的人（不包括投保人、被保险人或其业务伙伴、代理或亲属）。
“承认的医学院”是指“列入《世界医学院名录》、与世界医学教育联合会（WFME）和国际医学教育和研究促进基金会（FAIMER）合作的医学院”。
(bb）医疗上必要的
属于以下情况的任何可赔付的治疗、测试、用药、住院或住院的任何部分：
• 对于被保险人罹患的病症的医疗处理是必需的；且
• 在范围、期限或强度方面不得超过提供安全、充分、适当的医疗所需的水平；且
• 必须是执业医师开出处方的；且
• 必须符合公认的职业标准。
(cc）护士
按其提供治疗地的要求取得执业注册、得到我们的认可的护士。
(dd）未披露事项
投保人或被保险人没有声明或没有完全声明的重大事实（包括但不限于年龄、惯常居住国、既往症等），其可能影响我们对接受风险和适用的条款和条件的核保决定。
(ee）门诊治疗
执业医师在门诊诊所、执业医师诊疗室、或医院提供的非住院的治疗，不包括各种形式的替代治疗，比如（包括且不限于）中医、针灸和顺势疗法。
(ff）计划
卓越留学安心保个人医疗保障计划。
(gg）保单周年
从保险生效日或上一年续保日起一年后的相同月份和日期。
(hh）保单开始日
保险合同注明的保单生效日。
(ii）投保人
保险单上注明的卓越留学安心保个人医疗保障计划的保单持有人。投保人必须在投保时年满十八（18）周岁。
(jj）保险单
我们最新提供给您的以您作为投保人的协议文件。文件中注明被保险人、保单生效日及“保险计划表”，注明每个被保险人享有的最高保险金额。
(kk）保险期间
保险单或批单中注明的保险期间。
(ll）保前疾病
在保险责任开始时间之前已存在的任何病症：
• 被保险人已被诊断出的病症；或
• 被保险人因此而接受药物、医嘱或治疗；或
• 根据我们指定的执业医师的意见，投保人和（或）被保险人应该已经知道的；或
• 被保险人已出现过相关症状的，不管其是否已接受过执业医师的诊断。
(mm）保费
与我们商定的支付后方使本保险合同生效的金额。
(nn）处方
执业医师开出的用于治疗被保险人病症的门诊药品和敷料。为免生歧义，处方不包括维生素、补充剂、非处方药、草药、中药，即便执业医师已开立处方。
(oo）合理且惯常
我们或我们的医疗顾问认为是合理且惯常的的医疗费用或治疗，不超过在同一区域内类似级别的机构在提供相同或相当的治疗时的收费或治疗的一般水平。
为免生歧义，在比较收费或治疗时，我们将考虑提供治疗的医疗机构的程序和标准的复杂性。如果必要，我们将延迟赔付，直到我们认为该费用或治疗是适当的，但是我们不会延迟支付合理治疗费用。
如果费用高于惯常标准，或治疗不是合理且惯常的，我们将根据经验按惯常标准支付保险金额，剩余部分由您自己承担。
(pp）双人病房
医院中可容纳两人的标准级双人病房。
(qq）专科医生
在某个国家的相关医学会获得执照并注册成为专科医生的执业医师。
(rr）外科手术
手术或其他侵入式外科干预。
(ss）临终病症
被保险人最终诊断为将在十二（12）个月内死亡的病症。该诊断必须由专科医生证明，并由我们的执业医师确认。临终病症不包括存在人类免疫缺陷病毒（HIV）。
(tt）恐怖行动
恐怖主义者或恐怖主义组织使用暴力要挟、恐吓平民以达到政治、军事或宗教目的的行为。恐怖主义还包括相关政府证明或认定为恐怖主义行为的任何行为。
(uu）治疗
执业医师对病症进行的外科手术或内科治疗，包括：
• 诊 断
• 住院治疗
• 日间治疗
• 门诊治疗
为免生歧义，以上所列的任何治疗都将按保单中列明的保险计划表对被保险人予以赔付。
(vv）就诊
被保险人每次去执业医师处接受其对某一病症的诊断和（或）治疗的过程。
(ww）我们
安盛天平财产保险股份有限公司（“安盛天平”），即签发本保单的保险人。
(xx）年
保险责任开始时间或上次续保日起十二（12）个日历月。
(yy）您
保险单中列明的投保人。
x保险合同将承担在保险期间内，由于意外事故或疾病导致的，由医生实施的医疗上必要的保障范围内的合理且惯常的医疗费用，该费用须同时满足以下条件：
a) 实际发生的医疗费用须在保障范围内，具体参照“保险计划表”中注明的给付限额、免赔额、免赔比例和自付额 ；
对于有免赔额和（或）免赔比例及自付额的保障项目，我们将执行先减去免赔额，然后对剩余的可赔付的余额使用免赔比例和自付额，即（实际费用-免赔额）x 免赔比例-自付额。
注意：如果被保险人发生的费用超过给付限额，差额必须由您或被保险人支付。
b) 求诊费、检查检验费或其他医疗服务费用是合理且必需的，我们将按照广泛接受的医疗标准收费进行赔付，该医疗费用不得超过当地其他类似专业机构为同一性别,相似年龄,类似疾病的病患提供同等医疗服务收取的费用,且该费用是为了不对被保险人的身体状况产生负面影响所必须花费不可省去的费用。必要时我们可能会延时支付理赔款，直到我们确认收费是合理的。 我们可能相应扣减索赔金额中非合理、非必需的医疗费用。
c) 医疗上必要的、合理且惯常的费用；
d) 不属于除外责任中列明的任何医疗费用；
e) 发生在保险期间内的医疗费用，且到期应缴保险费已经全额付清。
5.1 保险责任给付说明
除非相关保险责任中另有说明，本合同下的保险责任无终身最高保额限制。任何有每日限额、金额限额或终身最高保额的保险责任将在以下条款中列明。
除非另有说明，保险责任还适用免赔额、免赔比例和自付额。
对于美国网络内医院或美国以外接受的治疗，适用 250 美元的免赔额和相关的免赔比例；对于美国网络外医院，适用 500 美元的免赔额和相关的免赔比例 。
具体的保险责任、给付标准和事先授权项目，请查阅第 8 条的“保险计划表 ”。
5.1.1 在美国之外的保险责任
我们承保被保险人在美国以外发生的可赔付的治疗，给付限额为每个被保险人每个保单年度
500 美元。
如果在美国以外接受治疗，被保险人必须先自己支付治疗费用，然后向我们提供收据进行理赔。
住院和日间治疗责任：
5.1.2 医院病房食宿费用
我们支付保障范围内在医院发生的双人病房的住宿费用还将支付被保险人在住院期间的标准餐费。该责任适用免赔额和免赔比例。
我们不支付医院提供的豪华病房、豪华套房或其他特殊病房的费用。如果被保险人所住病房高于保单列明的等级，则被保险人需要支付病房住宿费的差额。并且需承担由于病房升级而导致的其他治疗开支增加的部分。请在住院前提前与我们核实清楚，以免产生不必要的自付费用。
5.1.3 医院费用
以保险单所列给付限额为限，在扣除免赔额和免赔比例后，承担被保险人在住院期间产生的合理且必需的如下医疗费用：
a） 检查检验费用 b） 手术费用； c） 手术室费用；
d） 看护护理、药品和敷料费用；
e） 执业医师在手术中使用的手术器具费用，包括手术植入物；
f） 手术医生和麻醉师费用；
g） 重症监护室和加护病房费用；
h） 计算机断层扫描（CT）、核磁共振成像（MRI）、x 光和其他成熟的医学影像检查的费用；
i） 化疗和（或）放疗费用；
j） 肾透析费用。
5.1.4 器官移植费用
以保险单所列给付限额为限，在扣除免赔额和免赔比例后，承担被保险人因罹患疾病或遭受意外伤害需要进行的肾脏、心脏、肝脏、肺或骨髓移植手术的合理且必需的医疗费用。器官来源必需合法。但不承担获得该器官所需要的费用(包括但不限于交通费用)或捐献者引起的任何费用。
5.1.5 精神疾病治疗费用
以保险单所列给付限额为限，在扣除免赔额、免赔比例和自付额后，按其他可赔付的病症进行 赔付，但该治疗必须是由精神科医生进行的住院或门诊治疗。当被保险人有精神健康障碍时，才会涉及精神疾病治疗。精神疾病是指精神或情感疾病或障碍，通常表示大脑存在疾患，有明 显的行为症状；或者是心智或人格存在疾患，表现为异常行为；或者是行为举止上的疾病，表 现为社会越轨行为。精神或神经障碍包括：精神病、抑郁症、精神分裂症、躁狂抑郁症、观念 或纪律障碍。
5.1.6 试图自杀造成的受伤/自残伤害引起的医疗费用
以保险单所列给付限额为限，在扣除免赔额、免赔比例和自付额后，按其他可赔付的病症的进行赔付。
请注意：如果在申请本保险前被保险人已被诊断出注意力缺陷障碍、破坏性行为障碍或广泛性发展障碍，则不承担该保险责任，我们不予赔付该项目相关费用。
5.1.7 治疗酒精和成瘾性物品滥用的费用
以保险单所列给付限额为限，在扣除免赔额、免赔比例和自付额后，按其他可赔付的病症的进行赔付，但是该治疗必须在医院或执业医师诊所进行。我们将承担以下责任：
a） 在医院住院治疗以解毒酒精和成瘾性物品滥用；以及
b）在执业医师诊所治疗酒精和成瘾性物品滥用。
酒精滥用是指任何模式化或习惯性的酒精滥用，造成社会或职业功能障碍，不能完成任何重要 的职业、功课或家庭职责，因而造成生理依赖和（或）与戒断相关的适应状态（有身体症状）。
成瘾性物品滥用是指任何模式化或习惯性的药物滥用、吸烟或尼古丁依赖，造成社会或职业功 能障碍、不能完成任何重要的职业、功课或家庭职责，因而造成有身体症状的生理依赖和（或）与戒断相关的适应状态。
请注意：专门从事或主要治疗成瘾品使用障碍或上瘾的机构不在承保范围内。我们对用于治疗或预防酒精或成瘾性物品上瘾或依赖的产品费用也不予以支付，无论是否由执业医师开立处方。
5.1.8 治疗艾滋病（AIDS）、人类免疫缺陷病毒（HIV）和性传播疾病（STD）的费用
以保险单所列给付限额为限，在扣除免赔额、免赔比例和自付额后，按其他可赔付的病症进行赔付。只有被保险人在我们承保后才出现 AIDS、HIV 或性传播疾病的体征或症状，我们才进行赔付。
门诊治疗责任：
下表中列出了适用于每次门诊就诊时针对全科医生、专科医生和治疗地点（美国网络内医院、美国网络外医院和美国以外）的自付额。
门诊治疗责任 | 美国 （网络内医院） | 美国 （网络外医院） | 美国以外 |
每次就诊的自付额：被保险人到非大学学 生中心或学生健康中心的全科医生处就诊 | USD 25 | USD 50 | USD 25 |
每次就诊的自付额：被保险人到非大学学 生中心或学生健康中心的专科医师处就诊 | USD 50 | USD 100 | USD 50 |
如果治疗是在大学健康中心或学生健康中心进行的，我们将免除以上自付额。
5.1.9 门诊治疗费用
以保险单所列给付限额为限，在扣除免赔额、免赔比例和自付额后，我们将支付：
a) 门诊挂号费，咨询费
b) 检查检验费
c) 作为门诊患者接受的电脑断层扫描、磁共振成像、正电子发射断层扫描和步态扫描和其他常用、非实验性的医学影像技术的检查费；
d) 门诊接受的放疗和（或）化疗；
e) 门诊接受的肾透析；
f) 门诊外科手术。
5.1.10 门诊处方药费用
以保险单所列给付限额为限，在扣除自付额和免赔比例后，赔付该责任给付由执业医师开具的可赔付病症的处方药。以下不在责任范围内：更换丢失的、偷窃的、损坏的、到期的或退化的药品、非处方用品、无处方产品、以及支架或支撑用具。
按处方配药时，请向网络内的药房出示您的会员卡。
理赔时请将理赔申请表、付款收据和处方一起提交。
我们不承担超过医生规定数量的任何处方、或在医生开出最初的处方九十（90）天后进行药品重配所产生的费用。
请注意：任何使用三十（30）天以上的处方药或其他药物必须经过我们的事先授权。
5.1.11 急诊治疗费用
我们支付急诊治疗所产生的费用。如果急诊治疗后需要接受住院治疗，免赔额将不适用，而免赔比例和自付额仍然适用。
5.1.12 替代疗法费用
以保险单所列给付限额为限，在扣除免赔额和免赔比例后，本项赔付以每次就诊 50 美元、每个被保险人每个保单年度最多三十（30）次为限。
我们将支付职业治疗师、物理治疗师和语言治疗师在门诊对可赔付的病症提供的职业治疗、物理治疗和语言治疗费用。
以上提及的职业治疗师或语言治疗师须由我们认可、且在治疗地点执业注册，其提供的治疗必须在执业医师的医疗监督下进行。医疗监督意味着如需接受以上治疗，须由先主治医生诊断后提出转诊。
职业治疗师、物理治疗师或语言治疗师必须给出明确的治疗方案，包括预期治疗效果和结束时间。
5.1.13 针灸和顺势疗法费用
以保险单所列给付限额为限，在扣除免赔额和免赔比例后，本保险责任以每个被保险人每个保单年度500美元为限。在保险期间内承担被保险人接受由我们认可的、合格的医师，包括针灸师、顺势疗法医师所提供的诊断和/或治疗所产生的费用。
以保险单所列给付限额为限，承担被保险人由合格的针灸师或顺势疗法医师开具的包括但不限于处方药物、维生素的费用。
针灸师、顺势疗法医师必须给出明确的治疗方案，包括预期治疗效果和结束时间。
为免生歧义，我们不予支付任何在住院治疗、日间治疗或诊断过程中的针灸和顺势疗法所产生的费用。
产科责任：
5.1.14 产科治疗费用
以保险单所列给付限额为限，在扣除免赔额、免赔比例和自付额后，我们将从保险责任开始时间起给付以下项目费用，无等待期。被保险人须在我们承保后受孕，否则我们不承担该项责任：
a) 产前常规护理费用；
b) 在医院或执业医师诊所治疗产前和产后并发症的医疗费用；仅承担下列产前和产后并发症：
• 抗磷脂抗体综合征；
• 宫颈功能不全；
• 宫外孕；
• 妊娠糖尿病；
• 葡萄胎 –葡萄胎妊娠；
• 妊娠剧吐；
• 妊娠期胆汁淤积症；
• 先兆子痫 / 子x；
• RH 因子；
• 先兆流产；
• 产后大出血；
• 胎盘膜残留。
c) 在医院、或由注册的助产士在医院或家里接生的费用；
对于医疗上非必要的剖宫产，仅按同一医院的顺产费用承担。如无证据证明剖宫产是医疗上必需的，则视为医疗上非必要的剖宫产
d) 最高九十（90）天的产后常规护理费用
e) 最高九十（90）天的产后并发症费用；
f) 不孕不育的检查和治疗费用 该项责任不适用于被保险人的子女。
5.1.15 避孕费用
以保险单所列给付限额为限，我们将支付女性自愿绝育手术和相关服务及器材的费用，包括且不限于输卵管结扎和绝育植入物。我们仅承担手术本身的费用，不包括任何后续治疗、或自愿绝育引起的并发症费用。
我们还将支付执业医师开具的用于计划生育的避孕药或器材的费用，仅限于执业医师开具的且经 FDA 批准的项目，或由 FDA 批准作为替代品的通用等效物品：女性用避孕贴剂、避孕药、避孕环、避孕针、子宫帽、绝育植入物、隔膜、宫内节育器（IUD）和永久避孕方法（比如输卵管结扎）（终身仅限一次）。
此项保障不受免赔额或免赔比例的限制。
5.1.16 流产费用
以保险单所列的给付限额，在扣除免赔额、免赔比例和自付额后，此项保障以每个被保险人每个保单年度 500 美元为限。我们承保由执业医师进行的治疗性流产、或由执业医师在胚胎可独立存活前（即怀孕二十八（28）周内）进行的主动终止妊娠。我们承担该治疗性流产或主动终止妊娠引起的并发症的住院费用。本项保障以每个被保险人每个保单年度 500 美元为限。
主动终止妊娠：每年以一（1）次为限。治疗性终止妊娠：
只有在以下情况下才承担治疗性妊娠终止（也称作医疗建议终止或医疗建议流产）责任：i)继续妊娠母亲会有死亡危险；或 ii) 胎儿的病症会导致其在出生前或出生后不久即死亡
新生儿责任：
5.1.17 新生儿的早产、先天性疾病、异常的医疗费用
以保险单所列给付限额为限，在扣除免赔额、免赔比例和自付额后，此项保障仅承保同时满足以下条件的新生儿：
a）新生儿出生时，被保险人（即新生儿的父母）已在本保单下连续承保xxxxxxx（000）x；
x） 新生儿在出生后三十（30）天内被成功添加到父母为被保险人的保单；
c）被保险人（即新生儿的父母）和新生儿一直在保单下连续承保，而且在接受治疗时保单持续有效。
5.1.18 常规新生儿护理费用
以保险单所列给付限额为限，在扣除免赔额和免赔比例后，我们将支付被保险人的新生儿出生后在医院住院的费用，包括：
a) 新生儿出生后，新生儿及被保险人（其母亲）待在医院时所发生的常规护理保健的费用，但不得超过四（4）天；
b) 执业医师在新生儿出生后立即进行访视和诊疗的费用，但是访视次数不得超过每天一
（1）次。
该保险责任是在被保险人（即新生儿的母亲）的保单下提供的。
其他保险责任：
5.1.19 意外导致的牙科治疗费用
以保险单所列给付限额为限，在扣除免赔额、免赔比例和自付额后，该保险责任的给付以每个被保险人每个保单年度每颗天然牙齿 300 美元、总金额最高 600 美元为限。我们将支付因口腔外部意外事故而造成的牙科治疗的费用，且该治疗是由牙科执业医师进行的，且在意外发生前被保险人的保障持续有效。
下列情况不属于保险责任范围，我们将不予支付所产生的费用：
a) 任何食用或饮用形式而造成的受伤，即便是含有异物引起；或
b) 正常磨损造成的损坏；或
c) 参加除院际、校际、校内、运动俱乐部等之外的任何体育活动而造成的受伤；或
d) 刷牙或其他任何口腔卫生过程而造成的损伤；或
e) 受伤是非口腔外意外原因造成的；或
f) 受到意外伤害七（7）天内但损伤不明显；或
g) 首次意外受伤之日起十八（18）个月后发生的费用。
5.1.20 儿童牙科和眼科医疗费用
该保险责任仅适用于附属被保险人（主被保险人的子女），且该附属被保险人的年龄低于十九
（19）周岁。
在扣除免赔比例（在网络外医院就诊）后，我们将支付：
a） 门诊常规牙科检查、拔牙、补牙、洗牙/抛光、x 光检查、窝沟封闭、氟化物治疗、根管治疗、植牙、义齿桥托、义齿冠、牙周病、假牙、高嵌体和低嵌体产生的费用，每个保险期间以两（2）次为限。
b）由视力保健中心验光师实施的视力检查费用，通过该检查确定是否需要配戴矫正眼镜，以及是否需要开具处方。视力检查以每个保单期间一（1）次为限。
这项责任给付附属被保险人每个保单年度最高 150 美元的眼镜或隐形眼镜费用，即一副医疗上必要的且必须有验光师出具的屈光度报告的标准镜框或隐形眼镜。
5.1.21 健康筛查/预防保健费用
以保险单所列给付限额为限，我们仅承担以下所列项目的常规检查所产生的费用。常规检查是指由执业医师或医疗机构实施的身体检查，仅供预防或参考，不以诊断、治疗任何已显示、出现症状和/或诊断出的已知疾病或损伤为目的。
c） 成人胆固醇筛查，包括可能胆固醇偏高人群（男性三十五（35）周岁及以上、女性四十五（45）周岁及以上、及其他需要筛查年轻人）；
d） 高血压成人的糖尿病（2 型）筛查；
e） 慢性病高风险人群的膳食咨询；
f） 十五（15）周岁到六十五（65）周岁人群的 HIV 筛查，包括其他 HIV 易感人群的 HIV 筛查；
g） 成人免疫接种疫苗 — 不同疫苗的剂量、建议的接种年龄和建议的接种人群有所差异：
i） 成人的梅毒筛查。
此项保障不受免赔额或免赔比例的限制。
5.1.22 离院后康复治疗费用
以保险单所列给付限额为限，在扣除免赔额和免赔比例后，我们将支付离院后的康复治疗费用，以每个被保险人每个保单年度最多三十（30）天为限，且必须同时符合以下要求：
a） 该医疗机构必须是在其所在的州取得经营许可；
b） 由一名专业从事护理和（或）康复的执业医师进行；
c） 在一家我们承认的离院后康复治疗机构、医院或部门进行；
d） 治疗不能在门诊进行；
e） 在该机构开始住院治疗前，被保险人已经与我们书面商定好相关费用；
f） 所有治疗计划是由负责治疗患者疾病或受伤的执业医师制定的；
g） 从医院出院后。
请注意：以上治疗机构不包括休养、老人疗养、治疗酒精和成瘾品滥用、监护和（或）治疗精神健康障碍等机构。
5.1.23 临终关怀和姑息治疗
(a) 以保险单所列给付限额为限，在扣除免赔额和免赔比例后，该责任的终身最高限额以所有相关病症累计三十（30）天的住院治疗费用为限。经主治医生的诊断并提供书面证明，证实被保险人处于保障范围内的重症末期，经我们书面同意后，被保险人可在专业姑息治疗或临终关怀机构接受护理。一旦允许，所有的重症末期的护理、治疗医疗费用只能在本保险责任下支付，而不能在其他任何保险责任下支付。其他非重症末期的可保疾病不受限于本保障限额，按其他相应的保险责任承保。在临终关怀期间被保险人不可更改保险计划。当临终关怀期间跨越保单年度时，须全额支付下年度的保费，否则保单将在保单周年日终止。一旦理赔金额达到保单给付限额后，我们将不再支付任何医疗费用，无论该费用即将或已经发生。
5.1.24 家庭护理/ 私人护理责任
以保险单所列给付限额为限，在扣除免赔额和免赔比例后，本保障以每个被保险人每个保单年度最多一百（100）天为限。
只有在满足以下所有要求的前提下，我们才支付被保险人由护士在被保险人家中提供的护理费用：
a） 被保险人已从医院出院，出院前因为可赔付的病症而收治在重症监护室；
b） 经主治医生证明该项保险责任确系医疗上必需的；
c） 接受家庭护理前，须经我们书面同意；
d） 该护理是医疗上必需的，并非由于被保险人的家庭原因。
为免生歧义，该费用是指护士在被保险人家中实施护理服务所产生的费用。
对于临终病症，本保险责任只在“临终关怀和姑息治疗”责任下给付，且适用其相关限制。
5.1.25 院际、校际、校内、体育俱乐部运动导致的医疗费用
以保险单所列给付限额为限，在扣除免赔额和免赔比例后，该责任的保险金额以每个被保险人每个保单年度 1500 美元为限。对于参加学校组织的体育运动（比如院际、校际、校内、体育俱乐部运动等）而导致的疾病或受伤，我们支付由此发生的费用，但下列情形除外：
(a）被保险人参加某项运动或接受相关训练可获得薪酬或货币补偿，包括补助或赞助费（不包括被保险人只得到差旅费的情形）；
(b）因下述运动造成的受伤的的治疗费用：高空跳伞、悬崖跳水、以无照飞机飞行或作为学员飞行、武术、自由攀登、登山（带或不带绳索）、水肺潜水（深度超过十（10）米）、徒步跋涉到两千五百（2,500）米以上高度、蹦极跳、峡谷漂流、悬挂滑翔、滑翔伞或机动滑翔伞、跳伞、洞穴探险、滑雪道外滑雪或滑雪道外进行的其他冬季运动。
为免生歧义，以上活动造成天然牙齿的意外损伤不属于本保险责任的范围，该费用属于“意外造成的牙科治疗”的给付范围。
5.1.26 耐用医疗设备
以保险单所列给付限额为限，在扣除免赔额、免赔比例和自付额后，承担由医生开具处方的医 疗上必需的用于恢复被保险人身体功能的医疗辅助器械、设施或耐用医疗设备的费用，如：足 部矫形拱形支架、压力袜、助听器、助讲器(电子喉)、轮椅、拐杖、医用夹板和医用矫形支架。
5.1.27 本地道路救护车
在扣除免赔额后，我们承担被保险人因疾病或意外伤害而导致医疗上必需的紧急送往和（或）转送医院的救护车费用。我们将根据主治医生的意见最终确定该救护车使用是否为医疗上必 需。本保险责任不构成“全球紧急医疗救援”的一部分。
5.1.28 保前疾病
我们将从保险责任开始时间支付因任何保前疾病而发生的任何费用，无等待期，前提是：
a） 对于卓越安心留学保个人医疗保障计划投保单上所有的医学核保问题，投保人或被保险人的回答为“否”；或
b） 投保人或被保险人如实告知重大事实；或
c） 被保险人没有出现症状，或在我们看来，应该合理知道该情况；或
d） 被保险人已经出现症状，即便其尚未咨询过执业医师。
以下第 5.1.29 到 5.1.31 中的保障利益和服务由我们指定的全球救援公司代为提供。
如果全球救援公司未能提供服务，或在提供服务中存在任何过失（不论是否有意），我们不承担任何责任。
被保险人联系全球救援公司时，以下情况可以提供运送或送返服务：
a) 所有情况须经我们评估后认为有必要进行紧急运送或送返，且所有安排须由我们指定的全球救援公司进行，以确保相关费用在承保范围内；
b) 如果被保险人（或其家属）自行安排运送或送返，则相关费用不予承保。被保险人有权接受上述服务，并不意味着在紧急运送或送返后，其后续治疗可得到给付。所有这些治疗应取决于您的保障计划和保险条款。
c) 如果属于以下情况，我们将不承担紧急医疗运送或送返责任：
• 您的病症不需要立即接受急诊住院治疗；
• 您的病症不影响您旅行或工作；
• 您的病症不是直接或间接因为故意的自残伤害、自杀或试图自杀而造成的；
• 您的病症一定程度上与酒精、药品或物质滥用有关；
• 您的病症是因为参加某项可获得薪酬或货币补偿（包括补助和赞助费）的运动或接受相关培训而造成的（除非您只得到差旅费）；
• 您的病症是因为以下情况而造成的：高空跳伞、悬崖跳水、以无照飞机飞行或作为学员飞行、武术、自由攀登、登山（带或不带绳索）、水肺潜水（深度超过十（10）米）、徒步跋涉到两千五百（2,500）米以上高度、蹦极跳、峡谷漂流、悬挂滑翔、滑翔伞或机动滑翔伞、跳伞、洞穴探险、滑雪道外滑雪或滑雪道外进行的其他冬季运动；
• 运送涉及将您从船上、钻井平台或类似的离岸地点运送出来；
• 未在病情发展为紧急状况后三十（30）天内告知我们该情况（除非是无法告知我们）。
• 我们没有事先同意运送或送返；
• 您的病症是由以下因素造成的：核、生物或化学污染、战争（无论是否宣战）、外敌行为、入侵、内战、骚乱、叛乱、暴动、革命、推翻合法成立的政府、战争武器爆炸或类似的事件。
• 您到中华人民共和国（含香港、澳门和台湾）或美国国务院提示的，不要前往的旅游、度假或进行非重要事务的目的地休闲旅游时发生的紧急情况。
5.1.29 紧急医疗运送和送返
a）如果属于以下情况，我们将承担紧急运送的费用：
• 您需要立即紧急住院；以及
• 我们指定的医生和主治医生认为您目前使用的或离您最近的医疗机构不能提供您需要的治疗。如果我们同意您的紧急运送，将承担送返的费用。
如果您决定要到其他地方接受治疗，而我们认为最近的医疗机构足以对您进行治疗，那么我们将不承担运送或送返的费用，包括您决定返回您的惯常居住国接受治疗。
b）紧急医疗运送和送返保障的操作
如果您已急诊住院，但是您本人或主治医生认为当地的医疗机构不能为您提供适当的治疗，请立即拨打我们的紧急联系电话。
我们将指定一名能够对相关医疗机构进行评估的人员，按 5.1.29 开头所述的运送或送返服务进行处理。
c）我们将承担的费用：
如果我们指定的医生认为现有医疗机构不适合您的治疗，我们将承担如下费用：
• 将您运送到您正在接受治疗的国家中适合治疗的医疗机构；或
•将您运送到另外一个国家中适合治疗的医疗机构。
当您从运送到的医疗机构出院后，我们将承担费用将您送返到：
• 您惯常居住的地方或国家（一年中大多数时间被保险人居住或打算居住的国家）；或
• 您持有护照的国家。
我们将按事先同意的运送方式、运送或送返的日期和时间，承担相关的费用，还将承担我们选择的运送机构在运送过程中给您提供的必要的治疗费用。
d）旅行票据的处理
您或陪同您运送的其他人的未使用的旅行票据都属于我们的财产，请将票据都提供给我们。
e）是否可以到特定的国家接受治疗
您可以选择到特定的国家接受治疗，但是我们不承担前往该国的交通费用。您到达该国后，保险合同的条款正常适用。
5.1.30 遗体送返
a）去世后送返
如果您在所持护照国家之外的地方去世，我们将承担将您的遗体（遗体或骨灰）送回以下地点所在地的港口或机场的费用：
• 您惯常居住的国家（一年中大部分时间被保险人居住或打算居住的国家）；
• 您所持护照的国家。
5.1.31 陪同紧急运送送返
该保险责任以每个被保险人每个保单年度 5000 美元，终身最高限额十五（15）天为限。任何航空运输安排仅限于一张经济舱往返机票的费用。
a）被保险人的家庭成员或朋友是否可以陪同紧急运送送返
如果需要运送或送返的被保险人在十八（18）周岁以下，我们将安排一位十八（18）周岁以上的同伴陪同旅行，并承担合理和必要的运送和食宿费用。如果需要运送或送返的被保险人在十八（18）周岁以上，且我们认为在医疗上适当时，也可以安排陪同并承担以上费用。
被保险人到达运送的目的地后，我们将不再承担陪同人员的费用。
b）运送或送返本保单承保的附属被保险人，主被保险人将得到的赔付
该责任取决于附属被保险人是否从其惯常居住地运送或送返、以及当时是否与主被保险人同行。
如果主被保险人和本保单承保的附属被保险人一起出外旅行，在附属被保险人需要运送或送返时，我们将额外赔付主被保险人因为该运送或送返而引起的合理和必要的运送和食宿费用。该赔付的前提是我们认为主被保险人陪同该附属被保险人运送送返在医疗上是适当的。
如果主被保险人和附属被保险人都在其惯常居住地，而附属被保险人需要从该地运送或送返，我们将仅赔付主被保险人因为该运送或送返而引起的合理和必要的运送费用。但不赔付食宿费用。
以上赔付的前提是我们认为主被保险人陪同附属被保险人运送送返在医疗上是适当的。
5.1.32 意外死亡或永久残疾
以终身最高保额、给付限额、免赔额、免赔比例和自付额为限，我们将赔付保险期间xx意外事故导致的被保险人的死亡或永久残疾：
(a）意外死亡：赔付意外身故总金额（如果我们没有赔付过（b）中所列的永久残疾）；或
(b）永久残疾：经我们认可的伤残鉴定机构鉴定后，赔付以下任何一项导致的永久残疾的总金额：
• 双眼视力完全不可逆的失明；或
• 双耳完全永久失聪；或
• 失去下巴；或
• 失去双臂和双手；或
• 失去双腿或双脚；或
• 失去一（1）只手臂和一条（1）腿；或
• 失去一（1）只手臂和一只（1）脚；或
• 失去一（1）只手和一只（1）脚；或
• 失去一（1）只手和一条（1）腿；或
• 四（4）肢完全瘫痪。
为免生歧义，本保单的除外条款始终适用于本保障，但是对于因精神健康障碍 、酒精和药品滥用、自杀、试图自杀或自残伤害而造成的意外死亡或永久残疾，则不予赔付。
6.1 本公司不承担下列测试、检查、治疗、项目、病症、活动及其相关或后续的任何费用-：
a）暂时性的用于缓解症状的治疗，不包含针对潜在病症所做的治疗；
请注意：我们不会拒绝承担任何由执业医师提出的其它治愈性治疗方案的费用。但是，被保险人以任何理由拒绝接受有效可行的治疗而只要求暂时性缓解症状的治疗费用，我们将不予支付。但是如果暂时症状缓解治疗属于“临终关怀和姑息治疗”，我们将予以支付。
b）以人工方式或任何辅助受孕方式受孕的婴儿出生后九十（90）天内发生的治疗或任何在该时段内已产生需求的治疗；
c）直接与代孕相关的治疗，无论是否由被保险人充当代孕，或是作为该代孕婴儿的父母； d）胎儿手术（是指对子宫中的胎儿进行的治疗）；
e）对阳痿、精索静脉曲张或其任何后果的治疗； f）对性功能障碍或其任何后果的治疗；
g）变性手术或任何其它外科手术及药物治疗，包括因性别改变而引起的、或与其直接或间接相关的心理疗法或类似服务；
h）男性或女性自愿绝育后进行恢复而发生的费用，包括手术后的后续护理和并发症的治疗；
i）肥胖症治疗（体重指数 BMI 达三十（30）或以上）或因肥胖症而引起的或与其相关的病症的治疗；
j）任何形式的减肥手术而产生的或与其相关的费用，不考虑手术的理由。这包括且不限于安装胃束带、或进行袖状胃形成术；
k）去除身体任何部位的脂肪或多余组织，无论是否存在医学或心理需要（比如乳房缩小）； l）食欲抑制；
m）采集供体器官或组织的费用、或管理费用（比如（且不限于）供体检索），即便是本保单允许该移植；
n）育儿或其他培训班,比如（且不限于）产前培训班；各种培训、课程或计划, 比如（且不限于）戒除酒精、烟草、毒品或成瘾性物质。；
o）投保人本人、或投保人或被保险人的业务合作伙伴、代理人、家庭成员为被保险人提供的治疗，以及被保险人为自己进行的治疗，包括开具处方药物；
p）矫正眼睛屈光缺陷的治疗，比如远视、近视、散光；激光/镭射视力矫正手术；
q）各种学习障碍、教育问题、行为问题、体格发育或心理发育，包括对这些问题的评估或评级，包括且不限于读写障碍、运动障碍、自闭症、注意力不足过动症（ADHD）和言语问题；
r）自身从事精神健康行业的被保险人因其职业培训需要而接受的治疗； s）预防性治疗或测试（以确定（在无显著症状的情况下）是否存在病症）； t）因不在本保单承保范围的治疗而产生的费用，包括由此增加的治疗费用；
u）为消除由生理或自然原因导致的身体变化相关的症状而进行的治疗，比如衰老、更年期或青春期，基础疾病或外伤引起的治疗除外；
v）免疫接种，第 5.1.21 中规定的除外；
w）提供或安装外部假体、矫形器、医疗辅助器械的费用；被保险人的保险计划中明确列明为承保范围的除外（见“保险利益表”）；
x）种植牙、口腔正畸、牙周病、牙髓病、预防牙科以及其他常见的牙科治疗（比如填充），无论是谁提供的治疗，被保险人的保险计划中明确列明为承保范围的除外（见“保险计划表”）；
y）因为被保险人参加某项可获得薪酬或货币补偿（包括补助和赞助费）的运动或接受相关培训而发生的治疗，被保险人仅获得差旅费的除外；
z）因为以下情况而发生的治疗：高空跳伞、悬崖跳水、以无飞行许可的飞机飞行或作为学员飞行、武术、自由攀登、登山（带或不带绳索）、水肺潜水（深度超过十（10）米）、徒步跋涉到两千五百（2,500）米以上高度、蹦极跳、溪降、悬挂滑翔、滑翔伞或机动滑翔伞、跳伞、洞穴探险、滑雪道外滑雪或滑雪道外进行的其他冬季运动；
aa）因社会或家庭原因（比如旅游或家务费用）、或因那些与治疗无直接关系的原因而发生的费用；
bb）水疗、或在健康水疗、温泉、自然疗法诊所、健身中心或类似地点发生的费用，即便是注册为医院的机构，或是由注册执业医师提供的治疗；
cc）任何行政管理费、任何种类的报告、或根据条款规定与医疗无关的供给和（或）服务；电话费；
dd）以美元或人民币之外的货币进行理赔时产生的所有银行或信贷费用、汇兑损失； ee）对任何天然的补充剂或物质的要求，包括且不限于维生素、矿物质和有机物质；
ff）营养补充剂，包括且不限于特殊婴儿配方和化妆品，即使是医疗上推荐的、处方建议的或确认有治疗效果；
gg）干细胞的冷冻保存、获取或储存，作为可能发生的疾病、外伤的预防措施； hh）非医疗上必要的的治疗，或被视作是个人选择，或非合理和惯常的；
ii）家庭访视，比如（包括且不限于）执业医师、健康专业人员的访视，不包括第 5.1.24 中所述的家庭护理/ 私人护理；
jj）因完全可以在门诊治疗的病症而产生的住院治疗；
kk）基因测试、或基因测试后提供的必要的咨询，即使是这些测试是为了证明被保险人需要进行基因处理，以应对今后可能出现的病症。因为这些测试进行的目的是为了证明是否会出现病症，而不是治疗病症；
ll）一般洗漱用品，包括且不限于香波、肥皂、牙膏、漱口液、护肤液、保湿霜、洁面乳、沐浴乳、避孕药（除非第 5.1.15 中另有规定）、直接在药店柜台购买的非处方药；
mm）各种睡眠障碍，包括且不限于打鼾、失眠症、阻塞性睡眠呼吸暂停、或睡眠研究测试；
请注意：如果达到以下列明的所有标准，我们不会拒绝支付阻塞性睡眠呼吸暂停手术和首次睡眠研究测试的费用（每个被保险人终身最多只可享受一次睡眠研究测试费用理赔）：
(i）专科医生已经为被保险人开了其他治疗形式的处方，但是所有这些治疗都没有成功治愈受保人阻塞性睡眠呼吸暂停；
(ii）专科医生确认手术是医疗上必要的，否则会危及生命；
(iii）在进行阻塞性睡眠呼吸暂停手术时，被保险人已在本公司连续投保两（2）个保单年度；而且
(iv）我们已事先批准了该手术。 nn）头发脱落、更换或植发的-检查或治疗； oo）各种形式的粉刺；
pp）耳朵或身体打孔和刺青、或由此引发的治疗；
qq）住院治疗永久神经损伤超过连续九十（90）天、或被保险人处于永久植物人状态时进行的治疗。永久植物人状态是指无知觉、意识或大脑运转迹象的完全无反应的状态，即使可以睁开眼睛、无辅助地呼吸，但是其对刺激（比如呼喊他/她的名字、触摸）无反应。
rr）被保险人超出其合法权利行事而产生的费用。
ss）在中华人民共和国（包括香港、澳门和台湾）、联合国（UN）和（或）美利坚合众国
（USA）和（或）欧盟（EU）制裁的国家发生的费用、服务或治疗。有关这些国家的具体情况，可打电话给我们的客户服务团队进行咨询。
6.2 我们不承担以下的测试、检查、治疗、项目、病症、活动及其相关或后续的费用的保险责任-：
a）整容（美容）手术或治疗； b）与既往的整容或整形手术相关或需要的任何治疗；
c）医院中的特殊护理（必要且合理的医疗费用），除非是我们已书面同意或提前同意-；
d）使用尚未证明是有效的药品、或试验药品、或还处于临床试验阶段的药品。也就是说，如果被保险人在欧洲接受这种治疗的话，药品必须获得欧洲药品管理局的许可；在世界其他地方接受治疗的话，必须获得美国 FDA 的许可，而且必须在许可期限内使用。但是，如果在开始治疗前，该治疗已经被权威医疗机构证明是适当的，而且我们已经与执业医师书面商定了费用，那么会给予支付；
e）尚未被证明为有效、或处于试验阶段的治疗。已经被证明有效的治疗是指已经经过了适当的临床试验和评估的程序和步骤，在医学杂志上发表的报告中有足够的证据证明在特定的用途中是安全、有效的疗法。
6.3 我们不承担由以下情况造成的治疗、或紧急医疗运送和送返而产生的费用：核、生物或化学污染；从事或参与战争（无论是否宣战）、外敌行为、非法或犯罪行为、入侵、叛乱、暴动、革命、推翻合法成立的政府、战争武器爆炸或任何类似事件。这包括被保险人暴露于不必要的危险（比如到骚乱地区去当旁观者或观众）而需要的治疗。
请注意：如果恐怖行动没有造成核、生物或化学污染，那么我们会承担由此类恐怖行动而造成的保险责任范围内的费用。
6.4 我们对下列费用不承担赔偿责任：
a）因工伤事故而产生的治疗，而该治疗的费用可从事故发生地点或当时其他地方的现行政府法令规定的工伤保险或类似保险中获得补偿。如果能从第三方获得赔偿我们会自行决定是否承担此次赔偿责任。本公司保留追偿此类费用的权利。投保人或被保险人有义务告知该次事故是否与工作相关。
b）因第三方的疏忽或不当作法而引发的治疗。投保人或被保险人必须采取所有合理的措施，从第三方或第三方保险公司获取补偿。
如果能从第三方获得赔偿，我们会自行决定是否承担此次赔偿责任。投保人或被保险人有义务告知该次事故是否与工作相关、或是否因第三方疏忽或不当作法造成。
6.5 如果在开始治疗的三十（30）天内我们未收到完整的理赔申请资料，我们有权不予理赔。
7.1 生效日
在收到填写完整的投保申请书后，我们会对投保人的保险要求进行书面确认并收取全额保费，此时本保险合同才开始生效。
生效日将在保险合同中注明，我们允许您指定自投保申请日起 60 天内的任意一天为生效日。
7.2 续保缴费
7.2.1 本保险合同为一年期合同。在每一个保险期间届满前，我们会书面通知投保人下一年度保险合同的保险责任及承保条件。如果您已选择以银行代扣等方式支付保费，我们会在续保年度继续以同样的方式收取保费。请注意：如果我们没有收到全额保费，保险合同并未生效。如果由于您没有及时支付保费则续保流程操作终止，您需要重新进行投保。
7.2.2 我们对每年的保险费率不作保证，每年续保保费将由保险期限届满之日每个被保险人的周岁年龄、届时有效的保费率表和对所承保风险有重大影响的其他因素确定。
在保险合同续保日、或保费宽限期前支付规定的保费后，本保险合同将续期到下一个保险期间。每一个被保险人的续期保费是以保险合同续保日当时的周岁年龄为基准计算。
我们有权在保险合同续期时调整承保条件和/或费率，并至少于续期日三十（30）天前通知被保险人或投保人。
7.3 保险合同终止
根据本保险合同其他条款的规定，如果发生以下情况，本保险合同将自动终止（以其中最早发生的一条为准）：
a) 保险期间届满（北京时间 23:59）；
b) 被保险人不再持有美国 F-1 或 J-1 签证时；
c) 如果豁免学生医疗保险的申请未得到您就读学校的批准，且您于保险责任开始时间后四 十五（45）天内通知我们，经我们审核在此期间内未发生过理赔的，我们全额退还保费；
d） 被保险人（如，国际学生）身故时；
e） 由于任何律法规和（或）经济制裁的规定，本保险合同无法合法地履行；
f） 您向我们提交申请终止本保险合同的书面通知时 。保险合同将于申请日或书面申请上要求的日期终止，终止日不得追溯至申请日之前。
请注意：对于（f）的情况，无论该保单下是否发生过理赔，我们均不退还保费。如果您有客观原因需要终止本保单，请您提供相应证明文件，经过我们审核认可并确认当年保单年度内无理赔的，我们会同意退保并退还保费。经我们审核后，退还保费的计算方法请查阅第 7.15 “保险费退费表”。
如果您因为没有及时缴纳保费导致合同终止，请您重新提交投保申请并付清保费，经我们审核同意后方可生效。
7.4 宽限期
续期保费缴纳的宽限期为三十（30）天。在这个期限内，本保险合同有效。若在此期间内发生任何有效理赔，须您在宽限期内全额缴纳续保保费，我们方可完成该部分理赔的赔付。否则保单将自动终止，以上宽限期内发生的理赔我们也不会赔付。如果保险因为没有付清续保保费而终止，您必须向我们重新提交投保申请并由我们重新审批。
7.5 遵守保险合同条款
我们和被保险人都有义务遵守本保险合同的条款。
7.6 减少附属被保险人
投保人可向我们提交书面申请，要求减少附属被保险人，减保从提出申请之日或投保人书面申请上要求的日期开始生效，不得追溯至申请日之前生效。
如果减保的附属被保险人已经发生过理赔，则我们不退还保险费。减保的附属被保险人必须将已发放的会员卡退还给我们。
7.7 风险变化
如果被保险人的投保资格、或任何可能影响我们承保决定、保险责任的信息发生变化，投保 人需要及时通知本公司。本公司保留根据这些风险变化，保留改变保险责任或拒绝承保的权利。
7.8 欺诈/虚假理赔
您必须确保您或被保险人在任何时候向本公司提供真实、准确、完整的信息。如果您或被保险人提交或试图提交任何虚假理赔，本公司保留以下权利：
(i) 拒绝赔付；或
(ii) 拒绝续保；或
(iii) 终止保险合同。
如果本保险合同下发生任何虚假理赔，所有已付和（或）应付的保险金将予以撤销或收回（如果适用），本保险合同立即终止。如果本公司已经支付保险金，将扣除已支付保险金后，无息退还保费。
7.9 理赔结算
所有理赔保险金将以美元或人民币结算。如果被保险人要求支付的治疗费用或收到的服务支票
（包括直接寄给本公司或第三方服务提供方的支票）不是本公司要求的结算币种，这些款项和支票都将按照提供服务时有效的汇率进行兑换，具体汇率由保险人合理确定。
7.10 弃权
x公司对本保险合同任何条款或条件的弃权不影响本公司今后对这些条款或条件的执行。
7.11 责任免除
保险公司和投保人均不对任何机构或个人提供医疗服务的质量负责。本保险合同的被保险人无权基于医院、执业医师、其他医疗或服务提供方的作为或不作为追究本公司或投保人的责任。
7.12 合作
您、被保险人或其代表人应全力配合本公司和本公司的医疗团队（包括单独指定的执业医师），并且在本公司要求时，全面真实地告知您和/或被保险人知道或应该知道的所有重大事实和事项。签署任何能够帮助本公司从执业医师、医院、诊所或其他渠道获取与您或被保险人医疗费用相关的信息的文件。
7.13 其它赔偿来源
x保险合同保险金的支付是基于补偿原则的。若您或任何被保险人从任何其他来源（如其它商业保险机构、社会保险机构、负有赔偿责任的第三方）处已取得了部分赔偿，或有类似的保险保障，则本公司仅在保险合同规定限额内就属于保险责任且您从上述来源中未获得赔偿的部分支付相应的保险金。
7.14 代位求偿权
x公司拥有完全的代位求偿权，可以以投保人或被保险人的名义提起诉讼（费用由本公司承担），追索本保单下的任何赔款和/或从第三方获得的赔偿。
7.15 短期退保保费
只适用于年付保费而且没有发生过索赔的情况 | |
已经过的保险期间 | 退还已付保险费 |
保单生效后 45 天内（只适用于豁免美国大学生医疗保险的申请未获通过的情况） | 退还全额保费 |
不超过生效日后 2 个月 | 60% |
不超过生效日后 3 个月 | 50% |
不超过生效日后 4 个月 | 40% |
不超过生效日后 6 个月 | 25% |
超过生效日后 6 个月 | 无 |
7.16 其他特定的基本条款
7.16.1 双方在此声明，作为本公司履行责任的前提，投保人和被保险人同意，投保人提供的 或其代表被保险人以及被保险人向本公司提供的任何个人信息可以由本公司保存、使用和披 露，以便本公司或与本公司相关的个人/机构、或任何独立的第三方（中国境内或境外）能够：
(i) 处理和评估被保险人的申请、因保单而引起的任何事项以及保险承保范围的其他申请，和/或
(ii) 提供保险合同下的所有服务。
7.16.2 如果您（或被保险人）的地址有任何变动，需要书面通知本公司。您有权代表本保单中所承保的所有被保险人，因此本公司会将有关本保单的信函寄到您的地址。
7.16.3 被保险人的投保年龄，以有效身份证件（如居民身份证、护照、户口薄、出生证明等）登记的周岁年龄为准。若发生错误，则按以下规定处理。若按被保险人的周岁年龄所需收取的 保险费较高，则任何本保险合同下应付的索赔均应按照实际支付的保险费和该保险期间下应付 的保险费之比例按比例支付。若按被保险人的周岁年龄所需收取的保险费较低，则所有多缴 保险费将无息退还。若被保险人的真实年龄不能满足本保险合同的投保资格，则本公司将有 权取消该被保险人的资格，其相应的已缴纳的保险费将无息退还。如果对真实年龄不能满足本 保险合同投保资格的被保险人进行了给付，该被保险人必须将该给付退还给本公司，本公司 保留以您支付的保费抵消该赔付保险金的权利。
7.16.4 本公司不受任何与本保险合同相关的信托、抵押、留置、转让或其他交易的限制，会始终履行向投保人或被保险人及其指定人或法人代表（根据具体情况）支付本保单项下任何的赔偿责任。
7.16.5 只有在保险合同中中列明的个人才会被视作本保单的被保险人。如果投保人决定终止保险合同，则所有被保险人保障终止。
7.17 货币汇率
x保险合同中的所有金额均以美元为单位。在投保时，本公司只接受人民币付款。对于续期保费，本公司可接受美元或人民币付款。所有理赔将以美元或人民币结算。
如果需要进行货币兑换，本公司将采用费用发生之日（即住院和日间治疗的出院之日、或门诊治疗之日）当时的通行汇率来确定汇率。
7.18 指定和变更受益人
经被保险人同意，投保人可在投保时指定一名或一名以上个人作为受益人。当不止一名受益 人时，投保人可确定受益人的优先顺序以及身故给付金的分配比例。如果没有确定分配比例， 所有受益人有权平均分配身故给付金。如果受益人故意造成被保险人死亡、受伤、残疾、疾病，或试图谋害被保险人，将失去其受益人权利。
经被保险人同意，投保人可向本公司发出书面通知，变更受益人。只有在本公司进行登记并发出批单后，该变更才生效。对于受益人变更所造成的任何法律纠纷，本公司不承担责任。
身故给付金将支付给去世的被保险人的受益人。除另有规定外，如果列明的被保险人的受益人都已去世，那么身故给付金将支付给被保险人的继承人。
7.19 消费者信息保护
我国保护可以识别公民个人身份、以及涉及公民隐私的电子信息。任何机构或个人不得以偷窃或其他非法方式获取个人电子信息，也不得出售或非法提供个人电子信息给其他人。
在经营活动中收集或使用个人电子信息时，网络服务提供方、其他企业和公共机构应遵守合法、正当和必需的原则，明确表明其收集和使用信息的用途、方法和范围，在取得信息提供方的同 意后，才可以收集和使用信息，而且不得违反相关的法律法规和双方的协议。
如果网络服务提供方、其他企业和公共机构需要收集和使用个人电子信息，应公布其收集和使用信息的规则。
网络服务提供方、其他企业和公共机构及其员工在其经营活动中必须对收集的个人电子信息严格保密，不得泄露、歪曲或破坏这些信息，也不得出售或非法提供这些信息给其他人。
7.20 投保人、被保险人义务
7.20.1 交付保险费义务
除另有约定外，投保人应当在保险合同成立时交清保险费。
7.20.2 如实告知义务
订立保险合同，保险人就保险标的或者被保险人的有关情况提出询问的，投保人应当如实告知。投保人故意或者因重大过失未履行前款规定的义务，足以影响保险人决定是否同意承保或者提 高保险费率的，保险人有权解除本合同。投保人故意不履行如实告知义务的，保险人对于合同 解除前发生的保险事故，不承担给付保险金责任，并不退还保险费。
投保人因重大过失未履行如实告知义务，对保险事故的发生有严重影响的，保险人对于合同解除前发生的保险事故，不承担给付保险金责任，如果保险人已经给付保险金，将收回已给付保险金，并无息退还保费。
7.20.3 保险事故通知义务
投保人和被保险人知道保险事故发生后，应当及时通知保险人。故意或者因重大过失未及时通知，致使保险事故的性质、原因、损失程度等难以确定的，保险人对无法确定的部分，不承担给付保险金责任，但保险人通过其他途径已经及时知道或者应当及时知道保险事故发生的除外。上述约定，不包括因不可抗力而导致的迟延。
7.21 追偿权
如果本公司授权第三方支付了或直接支付了或者为被保险人利益直接对第三方支付了非本合同项下承保的费用或者支付额超出了相应的责任限额，或者额外支付了被保险人有权从其他来源处获得的赔偿，则本公司有权向被保险人追索上述金额或超额支付部分。
7.22 适用法律/法规
x合同的订立、效力、解释、履行及合同争议的解决，均受中华人民共和国（“中国”）法律管辖。投保人、被保险人、受益人与本公司之间因保险合同引起的或与保险合同有关的任何争议，如协商不成的，按下述方式之一解决：
1）中国国际经济贸易仲裁委员会，按照申请仲裁时该会现行有效的仲裁规则进行仲裁。该仲裁应按照中华人民共和国的法律执行。仲裁裁决是终局的，对双方均有约束力；或者
2）具有司法管辖权的中国法院裁判。
投保人、被保险人、受益人与保险人在保险合同签署时应确定上述方式之一作为争议解决方式。如果没有特别约定，则第二种方式为本合同默认的争议解决方式。
被保险人或受益人向保险人请求赔偿或给付保险金的诉讼时效期间为二年，自其知道或者应当知道保险事故发生之日起计算。
7.23 索赔流程
作为获得理赔的先决条件，您需要遵守以下时间要求和索赔流程：
a）被保险人须自保险事故发生之日起的三十（30）天内书面通知本公司。
b）本公司应向被保险人提供索赔申请表。被保险人须自保险事故发生之日起六十（60）天内 将索赔申请表，连同所有必要的表明被保险人身份的有关证件以及支持索赔的全部账单、证明、信息、和证据递交给本公司，包括但不限于医院出具的原始凭证，医疗诊断书、病理检查、化 验检查报告、门诊及住院医疗费用等原始单据、费用、账单结算明细表及处方。所有证明索赔 要求所必需的证明、 收据、信息和证据均应由您负责提供，并以认可的形式免费提供给本公 司。
c）在本公司的理赔审核过程中，本公司有权并在合理的范围内对索赔的被保险人进行医疗检查。此外，本公司应有权在法律允许情况下，要求尸检检验。此类检验费用由本公司承担。在拒赔的情形下，本公司将承担因您提供索赔要求所必需的证明、收据、信息和证据而产生的费用。
请查阅“会员指南”，了解本公司有关“一般查询”、“索赔”、“申请紧急医疗运送送返”的详细信息。
您也可以查阅“会员指南”，了解完整的流程和可提供的服务。
第 8 条 保险计划表
保险给付和保险责任表 （给付限额以美元计） | |||
终身最高保额： | 无限制 2 | ||
每次疾病/受伤的最高保额 | 无限制 2 | ||
报销水平 | 合理和惯常的费用 | ||
承保区域 | 美国 | ||
每个保单年度每个被保险人在承保区域外的最 高保额 | 500 美元 3 | ||
美国 （网络内） | 美国 （网络外） | 美国之外 | |
免赔额（每个保单年度每个被保险人） | 250 美元 | 500 美元 | 250 美元 |
按保险计划规定，适用于可赔付医疗费的免赔 比例（相关给付下另外注明的除外） | 扣除免赔额后 的 80% | 扣除免赔额后 的 60% | 扣除免赔额后 的 100% |
每个保单年度每个被保险人最高自付金额 9 | 6,350 美元 | 不适用 | 不适用 |
住院和日间治疗责任 | |||
医院病房食宿 – 双人病房 6 | 扣除免赔额后 的 80% | 扣除免赔额后 的 60% | 扣除免赔额后 的 100% |
医院费用 6 • 诊断； • 手术； • 手术室费用； • 护理、药品和敷料； • 外科器具和外科植入物； • 外科医生和麻醉师费用； • 重症监护室和加护病室费用； • CT、MRI、x 光和其他成熟的医学影像技术； • 化疗和（或）放疗； • 肾透析。 | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 100% |
器官移植 6 | 扣除免赔额后 的 80% | 扣除免赔额后 的 60% | 扣除免赔额后 的 100% |
精神疾病 6 （按任何其他适用的病情处理） | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 100% |
自杀未遂/自残伤害而造成的受伤 | 扣除免赔额 后的 80% | 扣除免赔额后 的 60% | 扣除免赔额后 的 100% |
酒精和和成瘾品滥用 6 | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 80% |
艾滋病、HIV 和性传播疾病 6 | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 80% |
门诊治疗责任 | |||
每次就诊的自付额：被保险人到非大学学生中 心或学生健康中心的全科医生处就诊 8 | 25 美元 | 50 美元 | 25 美元 |
每次就诊的自付额：被保险人到非大学学生中 心或学生健康中心的专科医师处就诊 8 | 50 美元 | 100 美元 | 50 美元 |
门诊治疗 6 • 就诊 7； • 诊断； • CT、PET、MRI； • 放疗和（或）化疗； • 肾透析； • 门诊手术。 | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 100% |
门诊处方药 4 6 (自付额不适用于本给付) | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 100% |
急诊治疗 （如为住院治疗，则免赔额不适用） | 扣除免赔额后的 100% | 扣除免赔额后的 100% | 扣除免赔额后的 100% |
治疗服务 6 • 职业疗法； • 物理疗法； • 语言疗法。 | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 100% |
按每次就诊 50 美元、每个保单年度每个被保 险人最多 30 天计算 | |||
针灸和顺势治疗 • 仅限于疾病相关的治疗 | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 100% |
按每个保单年度每个被保险人 500 美元计算 | |||
产科责任 | |||
受保孕妇的产科治疗 6 • 产前和产后的常规治疗 5； • 产前和产后的并发症 5； • 生产费用； • 不孕症的检查和治疗。 * 本保险责任不包括主被保险人的女儿。 * 本保险无等待期。 * 必须是在保单生效日后受孕的。 | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 80% |
避孕 6 (免赔额和免赔比例不适用于本给付） | 100% | 无给付 | 无给付 |
流产 6 | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 80% |
按每个保单年度每个被保险人 500 美元计算 | |||
新生儿责任 | |||
早产儿、先天性疾病、新生儿异常情况 | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 80% |
新生儿常规治疗 | 扣除免赔额 后的 80% | 扣除免赔额后 的 60% | 扣除免赔额后 的 100% |
其他保险责任 | |||
意外造成的牙科治疗 | 扣除免赔额 后的 80% | 扣除免赔额后 的 60% | 扣除免赔额后 的 100% |
按每个保单年度每个被保险人每颗牙齿 300 美 元，最高 600 美元计算 | |||
儿童牙科及眼科（19 岁以下受抚养子女） （免赔额不适用于本给付） | 100% | 70% | 无给付 |
门诊常规牙科检查按每个保单年度 2 次计算 视力检查按每个保单年度 1 次计算 眼睛和隐形眼镜按每个保单年度 150 美元计算 | |||
健康筛查/预防保健 (免赔额和免赔比例不适用于本给付） | 100% | 无给付 | 无给付 |
离院后康复治疗费用 6 | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 100% |
按每个保单年度每个被保险人最多 30 天计算 | |||
临终关怀和姑息治疗 6 | 扣除免赔额 后的 80% | 扣除免赔额后 的 60% | 扣除免赔额后 的 80% |
按终身最多 30 天计算 | |||
家庭护理/ 私人护理 6 | 扣除免赔额后的 80% | 扣除免赔额后的 60% | 扣除免赔额后的 80% |
按每个保单年度每个被保险人最多 100 天计算 | |||
院际、校际、校内、体育俱乐部运动等导致的治疗 6 | 扣除免赔额后的 80%; 每个保单年度每个被保险人最高 1500 美元 | 扣除免赔额后的 60%;每个保单年度每个被保险人最高1500 美元 | 扣除免赔额后的 80%;每个保单年度每个被保险人 500 美元 |
耐用医疗设备 6 | 扣除免赔额 后的 80% | 扣除免赔额后 的 60% | 扣除免赔额后 的 80% |
本地道路救护车 | 扣除免赔额后的 100% | ||
保前疾病 | 无等待期 | ||
未事先授权的罚金 | 可赔付金额的 50% | ||
紧急医疗运送和送返 10 | 无限制 | ||
遗体送返 10 | 无限制 | ||
陪同紧急运送送返 10 （免赔额和免赔比例不适用于本给付） | 每个保单年度每个被保险人 5,000 美元，终身 最多 15 天 | ||
意外死亡和永久残疾 | 主金额 – 终身最高金额 25,000 美元（被保险人） 10,000 美元（配偶） 5,000 美元（子女） | ||
注：
1. 本保险计划表是对卓越留学安心保个人医疗保障计划的相关给付情况的简要说明。请查阅保险合同，了解更详细的说明，以及给付的条款和条件。
2. 最高终身保额是无限制的，除非是在相关给付下注明了限额。
3. 美国之外的承保金额扣除免赔额和免赔比例后最高 500 美元（所有给付应累计计算）。
4. 使用超过三十（30）天的任何处方药或其他药物应由本公司预先批准。
5.我们将支付产后常规治疗和产后并发症的费用，最多以婴儿出生后九十（90）天为限。
6. 事先授权是强制性的，否则，被保险人必须承担扣除免赔额、免赔比例和自付额（如果适用）后费用的百分之五十（50%）。
7. 事先授权不适用于门诊就诊。
8. 自付额不适用于大学学生中心或学生健康中心的门诊治疗。
9. 最高年自付金额是指每个被保险人在保单年度须自己承担的最高保险金额，包括免赔额、自付额和免赔比例。一旦达到该金额，保险责任按相应的保障范围 100%支付。
以下费用不累计计算在最高年自付金额中：
a) 非承保范围的服务和用品产生的费用，或超过保险责任最高限额的费用；
b) 未事先授权的。
10. 此服务均应由我们指定的国际援助公司提供。我们不承担超出该公司经营范围的服务费用或未经我们安排的服务而产生的费用。
AXA Tianping Property & Casualty Insurance Company Limited
Tel: 95550
StudentCare Exclusive
This Policy, Policy Schedule, Certificate of Insurance, Application Form, Endorsement and Supplementary Agreement shall be read together as an entire contract
Welcome to StudentCare Exclusive Policy.
Please read this policy carefully together with your policy schedule to ensure that you understand the terms and conditions and that the cover you require is being provided. Do keep it in a safe place.
If you have any questions after reading these documents, please contact AXA Tianping Property & Casualty Insurance Company Limited.
If there are any changes that may affect the insurance provided, please notify us immediately.
Caring For Our Customers.
We are committed to provide satisfaction to our customers by:
• Listening closely and understanding your needs
• Providing you the advice with any general enquiries you may have
• Delivering prompt and efficient services
Table of Contents
From Pages
Section 1 Introduction 3
Section 2 Eligibility 4
Section 3 Pre- certification Criteria 5
Section 4 Definitions 6
Section 5 What you are covered for 12
Section 6 Exclusions and limitations 27
Section 7 General Conditions 31
Section 8 Benefits Table 39
Section 1 - Introduction
This policy has been designed to set out all the features and benefits of the StudentCare Exclusive plan. On the next few pages you will find details of the cover followed by the terms and conditions.
1.1 What your healthcare insurance cover is designed to do
StudentCare Exclusive is a health insurance which covers the international student as well as his/her dependent spouse and/or child(ren) against the cost of medically necessary eligible treatment resulting from unexpected illness or accident.
1.2 A personal service
At AXA Tianping Property & Casualty Insurance Company Limited (‘AXA Tianping’), we are always aware that behind every claim there is a person who needs help and assistance. If there is anything you do not understand, please do not hesitate to call our AXA Customer Care Centre.
1.3 What our Customer Service team is here to do
It is the role of our Customer Service team to assist you and the covered person, wherever possible, within the terms and limits of the StudentCare Exclusive plan. You will find the number of our Customer Service team on the reverse of the membership card.
For your own protection, calls may be recorded in case of subsequent query or for training purposes.
Please take note of this and covered person to keep their membership card in a safe place where they can find it easily. Please have the membership card with you whenever you call our Customer Service team. The information on membership card will help them to deal with your enquiry as quickly as possible.
1.4 What this policy means
This document sets out the terms of your policy with us and must be read in conjunction with any supplementary documentation we provide to you from time to time (e.g. the policy schedule and membership card etc.). We have tried to keep this as clear as possible however, if there is anything you do not understand or would like to clarify, please contact us. Decisions regarding the benefits and/or changes to the terms of the policy cannot be made verbally but must be confirmed by us in writing.
In this policy document you will find detailed definitions, terms and exclusions forming part of the contract between you and us. Please read them carefully and ask us if there is anything you or the covered person do not understand.
1.5 Free look provision
You have a free-look period of thirty (30) business days from the date that you receive this policy document to review it. You are deemed to have received the policy document within three (3) days after we have dispatched it. If you decide that this policy does not suit your needs, you may request to cancel it by giving us clear, written instructions and returning the policy documents and membership card (s) to us within the free-look period. Provided that no claims have been made during this period, we shall refund the premium paid by you, in full, without interest. It will also not apply to policy renewals.
Section 2 – Eligibility
2.1 Eligibility
An insured person must fulfil all the following criteria where applicable, to be eligible for coverage under this policy:
a) an international student with a valid USA F-1 or J-1 visa,
b) physically reside in USA for at least ninety (90) days, and actively attending classes as an international student for at least the first thirty-one (31) days after the effective date of coverage,
c) nationality is a citizen of Greater China,
d) maximum entry age is sixty-five (65) years old, and maximum coverage age is seventy (70) years old,
e) the dependent of the insured person must be age at least fifteen (15) days old,
f) submit the application form to us and we have confirmed their coverage in writing.
Please note: (e) and (f) are not applicable to new born baby included during the policy year without underwriting.
The Company maintains its right to investigate student’s status and attendance records to verify that the policy eligibility requirements have been met.
A dependent can be eligible for coverage under the same policy as the insured person (i.e. the international student),if they have a valid USA F-2 or J-2 visa and fulfil the applicable criteria stated in Section2.1. Dependent eligibility expires concurrently with that of the person insured (i.e. the international student).
A USA citizen is not eligible for coverage under this policy as an insured person or as a dependent, and this apply to any covered person who has a dual nationality.
For avoidance of doubt, if the international student or dependent has dual nationality, one of the nationality must be a citizen of Greater China, and he/she has been residing in China for more than one hundred and eighty-five (185) days prior to applying the StudentCare Exclusive.
Important Note:
In some cases we may not be able to cover you where to do so would render us subject to legal or regulatory action whether under international or domestic law. We and other service providers will not provide cover or pay claims under this policy if doing so would expose us or the service provider to a breach of international economic sanctions, laws or regulations, including but not limited to those provided for by the European Union, United Kingdom, United States of America, Greater China or under an United Nations resolution. If a potential breach is discovered, where possible we will advise you in writing as soon as we can. Under no circumstances shall this policy be deemed to provide cover and no liability be incurred to pay or provide any benefit hereunder to the extent that the provision of such cover, payment of such claim or provision of such benefit would cause to us to be in breach of, or expose us to any prohibition, or restriction under the laws or regulations of Greater China .
2.2 Adding a new born baby
New born baby may be added to the international student’s policy during the policy year without underwriting, by paying the applicable premium and enjoy cover commencing at the time of birth provided all the following criteria is fulfilled:
a) we are requested to add that baby to the parent’s policy within thirty (30) days from the time of his/her birth,
b) baby is not conceived via assisted conception,
c) baby has been discharged from the hospital,
d) baby is not an adopted child or born from a surrogate parent,
e) the parent has been continuously covered under the policy for at least three hundred and sixty-five (365) days when the baby is born.
If any of the requirements stated in Section 2.2 is not met, the new born baby may be added to the policy, subjected to underwriting. the new born baby must be at least fifteen (15) days old at time of application, he/she must has been fully discharged from the hospital at the time of enrolment into this policy, and the parent must submit evidence of insurability. The cover will commence only when we have confirmed their coverage in writing.
Section 3 – Pre- certification Criteria
Pre-certification for all treatments are compulsory, otherwise, the covered person will be required to bear fifty percent (50%) of the eligible expenses i.e. eligible expenses after deductible, co-insurance and co-payment (if applicable).
Pre-certification is not compulsory for emergency services or treatment in the emergency room (or otherwise advised by us).
For benefits listed under the Section - International Emergency Medical Assistance (IEMA) pre- certification is by the international assistance company we have engaged or by us.
Please refer to the benefits table in Section 8 for further information on the benefits that require compulsory pre- certification.
Pre-certification is compulsory to protect you and the covered person from unexpected costs. When issuing confirmation of cover in this way, we confirm the following:
• the planned treatment is eligible under your policy
• the planned treatment is medically necessary
• the planned treatment is within reasonable and customary cost
• the planned treatment cost falls within the remaining benefit limit of your plan
Pre-certification is compulsory for the following treatments and services:
• Hospital Charges
• Organ Transplant
• Mental Health
• Alcohol and Substance Abuse
• Acquired Immune Deficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV) and Sexually Transmitted Diseases (STD)
• Out-patient Treatment
• Therapeutic Services
• Maternity Care for covered pregnancy
• Contraception
• Abortion
• Extended Care / Inpatient Clinics /in-patient Rehabilitation
• Hospice and palliative care
• Home Health Nurse / Skilled Nursing / In-Home Nurse / Private Duty Nurse
• Intercollegiate, interscholastic, intramural, club sports, etc.
• Durable Medical Equipment Please note:
1. Pre- certification for the following services is compulsory.
2. In the event that our chosen international assistance company was not informed that such services were required by the covered person nor these services were not arranged by us or our chosen international assistance company, no benefit is payable.
• Emergency Medical Evacuation and Repatriation
• Repatriation of Remains
• Emergency Reunion
Section 4 –Definitions
(a) Abortion
Refers to deliberate termination of pregnancy, most often within the first twenty-eight (28) weeks from conception. This term is also affiliated with Therapeutic Termination of Pregnancy, which means willful termination of pregnancy determined to be medically necessary for the health and well-being of the mother or female.
(b) Accident/accidental
Refers to any external, sudden, non-disease, unforeseen, visible, violent and unexpected physical event beyond the control of the covered person resulting in bodily injury.
(c) Acute
Refers to a disease, illness or injury that is likely to respond quickly to treatment which aims to return the covered person to the state of health the covered person was in, immediately before suffering the disease, illness or injury, or which leads to the covered person’s full recovery.
(d) Application Form
Refers to the form which contains the underwriting questions that the policyholder must complete for all the persons to be insured in this policy.
(e) Age/aged
Refers to the covered person’s attained age based on his/her last birthday (and the expression “Aged”
shall be construed accordingly).
(f) Assisted conception
Refers to the use of medical technology to increase the number of eggs during ovulation or to bring a human sperm and an egg, or eggs, close together, thereby increasing the chance of conception. This includes but is not limited to intra-uterine insemination (IUI), in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI) or the use of any form of treatment to induce or increase ovulation. This includes surrogate conceptions.
(g) Benefits Table
Refers to the table applicable to the covered person’s plan stated in Section 8 showing the maximum benefits we will pay for each covered person.
(h) Congenital conditions
Refers to a genetic (including hereditary condition), physical or biochemical defect or disease, malformation or anomaly, present at birth and whether or not manifest, diagnosed or known about at birth.
(i) Co-insurance
Refers to a share of the eligible medical expenses that you and/or the covered person need to pay after the deductible. Please refer to the benefits table for the co-insurance percentages.
(j)Co- payment
Refers to amount stated that you and/or the covered person need to pay after the deductible and the co-insurance. This is only applicable to expenses incurred for all treatments provided on an out- patient basis by a general practitioner and/or specialist, unless otherwise stated in the benefits table.
(k) Covered person
Refers to the insured person (i.e. the international student) and/or the dependent(s) (i.e. the legal spouse or child of the insured person) covered under the policy.
(l) Day-care treatment
Refers to an eligible treatment (excluding out-patient treatment) at a hospital or day-care unit (where a discharge summary is issued by the hospital) and the covered person requires a medically supervised recovery but does not occupy a bed overnight. This excludes all forms of alternative
treatment such as, but not limited to, traditional Chinese medicine, acupuncture and homeopathy.
(m) Deductible
Refers to the part of the benefit being claimed that the covered person must pay before we will pay any benefit during the policy year. The deductible is shown in the benefits table applicable to the covered person’s plan and this applies to each visit.
(n) Dental practitioner
Refers to a person (other than you, the covered person or a business partner or a relative of yours or the covered person) who, being recognized by us, has the primary degree in dentistry following attendance at a recognized dentistry school, who is licensed and registered with the relevant statutory dental board or council to provide dental treatment.
(o) Dependent(s)
Refers to the (i) legal spouse, or (ii) unmarried legal child(ren) (or those of the legal spouse) of the insured person (i.e. the international student), who is/are living with the insured person when he/she takes up the policy or when this policy is renewed. For the dependent child who is eligible under this policy, he/she cannot stay on the policy after the policy anniversary following his/her twenty-first (21st) birthday.
However, his/her cover may be renewed up to the age of twenty-five (25) years old provided he/she is unmarried and is still a full time student in an educational institution.
(p) Diagnostic procedures
Refers to consultations and investigations needed to establish a diagnosis for an eligible treatment
where there are symptoms.
(q) Eligible treatment
Refers to those medically necessary treatments and charges that are covered by this policy. In order to determine whether a treatment or charge is covered, all sections of this policy document should be read together, and are subject to all the terms, benefits and exclusions set out in this policy document.
(r) Emergency
Refers to a sudden, unexpected acute medical condition which, in our opinion, constitutes a serious or life threatening emergency which requires immediate surgical or medical attention to avoid death or permanent and irreversible total loss of function.
(s) Endorsement
Refers to the supplementary document we issue to the policyholder to record and confirm changes to this policy document.
(t) Evacuation or Repatriation
Refers to moving the covered person to another hospital which has the necessary medical facilities either in the country where the covered person is taken ill or in another nearby country (evacuation) or bringing the covered person back to his/her principal country of residence or his/her home country (repatriation). The service includes any medically necessary treatment administered by the service provider appointed by us while they are moving the covered person.
(u) Hospital(s)
Refers to any establishment which is licensed as a medical or surgical hospital or provider in the country where it operates and which is recognized by us and it meets all the following requirements:
• it operates primarily for the reception, care and treatment of sick, ailing, or injured persons as in- patients;
• it provides twenty-four (24) hours a day nursing service by nurses;
• it has a staff of one or more licensed medical practitioners available at all times;
• it provides organized facilities for diagnosis and major surgical facilities;
• it is not primarily a nursing home, rest home, convalescent home or similar establishment, geriatric ward, an institution for treatment of substance abuse, such as, but not limited to, alcoholic or drug rehabilitation or similar purposes.
(v) In-patient treatment
Refers to eligible treatment at a hospital where the covered person has to stay in a hospital bed for one or more nights. This excludes all forms of alternative treatment such as, but not limited to, traditional Chinese medicine, acupuncture and homeopathy.
(w) Insured person
Refers to the international student with a valid USA F-1 or J-1 visa, and with an insurable interest with the policyholder and as stated in the policy schedule.
(x) Intensive care unit
Refers to a section within a hospital which is designated as an intensive care unit by the hospital and which is maintained on a twenty-four (24) hours basis solely for treatment of patients in critical condition and is equipped to provide special nursing and medical services not available elsewhere in the hospital.
(y) Lifetime
Refers to the period in which the applicable covered person is alive. This does not refer to the duration of the policy.
(z) Greater China
Refers to Mainland China, Hong Kong, Macau and Taiwan.
(aa) Medical condition(s)
Refers to any eligible disease, illness or injury covered by this policy.
(bb) Medical practitioner(s)
Refers to a person (other than you, the covered person, a business partner, the agent or relative of yours or the covered person) who, being recognized by us, has primary degree in the practice of western medicine and surgery following attendance at a recognized medical school and who is licensed to practice western medicine by the relevant licensing authority where the treatment is given.
By ‘recognized medical school’ we mean “a medical school which is listed in the World Directory of Medical Schools, which is in collaboration with the World Federation for Medical Education (WFME) and the Foundation for Advancement of International Medical Education and Research (FAIMER).“
(cc) Medically necessary
Refers to any eligible treatment, test, medication, or stay in hospital or part of a stay in hospital which:
• is required for the medical management of an eligible medical condition suffered by your covered person; and
• must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity; and
• must have been prescribed by a medical practitioner; and
• must conform to the professional standards widely accepted. (dd) Nurse(s)
Refers to a qualified nurse who is registered to practice as such where the treatment is given and is recognized by us.
(ee) Non-disclosure
Refers to material facts (facts that would influence our underwriting decision to accept the risk and the terms and conditions that should apply) that are either not declared or that have not been declared fully by the policyholder or the covered person.
(ff) Out-patient treatment
Refers to eligible treatment by a medical practitioner at an out-patient clinic, a medical practitioner’s consulting room, or in a hospital where the covered person is not admitted to a bed. For avoidance of doubt, this excludes all forms of alternative treatment such as, but not limited to, traditional Chinese medicine, acupuncture and homeopathy.
(gg) Plan
Refers to the StudentCare Exclusive plan.
(hh) Policy anniversary
Refers to the same date and month following a year from the policy commencement date or last policy anniversary.
(ii)Policy commencement date
Refers to the date on which the insurance coverage starts as set forth in the policy schedule. (jj) Policyholder
Refers to the person named on the policy schedule and he/she is the owner of the StudentCare Exclusive plan. The policyholder must be aged at least eighteen (18) years old at time of application to be eligible as the policyholder.
(kk) Policy Schedule
Refers to the most recent document forwarded to you by us which forms part of the agreement we have with you which allows you to be registered as the policyholder. This document sets out who is the covered person, when cover begins. It also sets out the benefits table showing the maximum benefits we pay for each covered person.
(ll) Policy year
Refers to each term of cover under the policy, which is stated in the policy schedule or endorsement.
(mm) Pre-existing condition(s)
Refers to any medical condition preceding the policy commencement date:
• the covered person has been diagnosed; or,
• for which the covered person has received medication, advice or treatment; or,
• which the policyholder and/or the covered person should reasonably, based on our appointed independent medical practitioner’s opinion, have known about; or,
• for which the covered person has experienced symptoms even if the covered person has not consulted a medical practitioner.
(nn) Premium
Refers to the amount as agreed with us to be paid to us to keep this policy in force.
(oo) Prescription(s)
Refers to out-patient drugs and dressings as prescribed by a medical practitioner for the treatment of a medical condition covered by the covered person’s plan. For avoidance of doubt, prescription will not include vitamins nor supplements nor over the counter medication nor herbal medication nor traditional Chinese medicine, even if they are prescribed by a medical practitioner.
(pp) Reasonable and customary
Refers to charges or treatment for medical care which shall be considered by us or by our medical advisers to be reasonable and customary to the extent that they do not exceed the general level of charges or treatment being made by others of similar standing in the locality where the charges or treatment are incurred when giving like or comparable treatment.
For the avoidance of doubt when comparing charges or treatment, we will take into account the complexity of the procedure and the standard of the medical facility where the treatment is received. If necessary, we may delay paying the claim until we are satisfied that the charges or treatments are appropriate, but we will not unreasonably delay paying the treatment.
If the charges are higher than is customary or the treatment is not reasonable and customary, we will only pay the amount which is, in our experience, customarily charged and you will have to pay the rest.
(qq) Semi-Private Room
Refers to a semi-private room in a standard class in a hospital which is equipped to accommodate two persons.
(rr) Specialist
Refers to a medical practitioner who is licensed and registered in the specialist register of the applicable medical council of a country.
(ss) Surgical procedure(s)
Refers to operations or other invasive surgical interventions.
(tt) Terminal medical condition
Refers to the conclusive diagnosis of an illness that is expected to result in the death of the covered person within twelve (12) months. This diagnosis must be supported by a specialist and confirmed by our medical practitioner. Terminal medical condition in the presence of Human Immunodeficiency Virus (HIV) is excluded.
(uu) Terrorist act
Refers to any use of violence by an individual terrorist or a terrorist group to coerce or intimidate the civilian population to achieve a political, military, social or religious goal. Terrorism shall also include any act which is verified or recognized by the relevant Government as an act of terrorism.
(vv) Treatment(s)
Refers to surgical procedures or medical procedures carried out by a medical practitioner for an eligible medical condition and this may include:
• diagnostic procedures
• in-patient treatment
• day-care treatment
• out-patient treatment
For avoidance of doubt, any of the above listed treatment is subject to the benefits table applicable to the covered person’s plan stated in the policy schedule.
(ww) Visit
Refers to each separate occasion that the covered person meets with a medical practitioner and receives a consultation and/or treatment for an eligible medical condition.
(xx) we/us/our
Refers to AXA Tianping Property & Casualty Insurance Company Limited (‘AXA Tianping’), being the
insurer issuing the policy.
(yy) Year
Refers to twelve (12) calendar months from when the policy began or was last renewed.
(zz) you
Refers to the policyholder and the covered person named on the policy schedule.
Section 5 – What you are covered for
This policy covers the covered person against the cost of medically necessary and eligible treatment
carried out by a medical practitioner. We will only pay:
a) for charges actually incurred for items listed in the benefits table applicable to the covered person’s plan subject to the benefit limits, deductible, co-insurance and co-payment shown in the benefits table.
For those benefits where there is deductible and/or co-insurance and co-payment, we will subtract the deductible first, then apply the co-insurance and co-payment to the balance of the eligible benefit remaining;
Note: if a covered person incurs costs in excess of the limits, you or the covered person will have to pay the difference.
b) charges by the medical practitioner, laboratory or other such medical services which are reasonable and customary. We may delay paying the claim until we are satisfied that the charges are appropriate. If the charges made by the medical practitioner, laboratory or other
such medical services are higher than is reasonable and customary, we will only pay the amount which is reasonable and customary and you or the covered person will have to pay the rest;
c) treatment that is medically necessary, reasonable and customary;
d) provided the costs or treatment are not for something excluded by the terms of this policy;
e) for eligible treatment incurred during a policy year for which the premium has been paid;
5.1 – Benefits Descriptions
The benefits under this policy has an unlimited lifetime maximum, unless otherwise stated in the benefit descriptions. Any benefits subject to day limit, amount limit or lifetime maximum will be stated in the policy descriptions.
The benefits are also subject to deductible, co-insurance and co-payment, unless otherwise stated.
If treatment is received from an in-network provider and outside USA, USD 250 deductible and applicable co-insurance will be applied, and any treatment is received from an out-network provider, USD 500 deductible and applicable co-insurance will be applied.
For availability of the benefits, benefit levels of the plan and benefits that require compulsory pre- certification, please refer to the benefits table on Section 8.
5.1.1 Coverage outside USA
This is to cover eligible treatment while the covered person is outside USA up to a limit of USD 500 per covered person per policy year.
When the treatment is received outside of the USA, the covered person might have to pay for the
treatment cost out-of-pocket and submit the receipts for reimbursement to us. In-patient and day-care treatment benefits:
5.1.2 Hospital Room and Board
While the covered person is admitted as an in-patient or day-patient for an eligible medical condition, we will pay for the costs of the covered person’s accommodation up to a standard semi-private room. We will also pay for the covered person’s standard meals during his/her stay in the hospital. This benefit is subject to deductible and co-insurance.
We will not pay for deluxe rooms, luxury suites or other special rooms that are available in the hospital. If the covered person stays in a room which is more expensive than the standard semi-private room, the covered person would have to pay for the difference in room charges and the share of other medical expenses which has increased as a result of the room upgrade. Please check with us prior to admission to avoid unnecessary out of pocket expenses.
5.1.3 Hospital Charges
Subject to the benefit limit, deductible and co-insurance, we will pay for hospital charges incurred for eligible treatment related to the admission, and given by a medical practitioner between admission and discharge such as:
a) diagnostic procedures
b) surgical procedures
c) operating theatre charges
d) nursing care, drugs and dressings
e) surgical appliances used by the medical practitioner during surgery, including surgical implants.
f) surgeon and anaesthetist charges
g) intensive care unit and high dependency unit charges
h) computerized tomography, magnetic resonance imaging, x-rays and other such proven medical imaging techniques
i) chemotherapy and/or radiotherapy
j) kidney dialysis
5.1.4 Organ Transplant
Subject to the benefit limit, deductible and co-insurance, we will pay for transplantation of kidneys, heart, liver, lung or bone marrow required as a result of an eligible medical condition and provided these organ(s) came from a relative or a certified and verified source of donation. The policy does not cover the costs of collecting donor organs (including but not limited to, transportation and administration costs) or any expenses incurred by the donor.
5.1.5 Mental Health
Subject to the benefit limit, deductible, co-insurance and co-payment, this is treated as any other eligible medical condition but the treatment must be provided by a psychiatrist on an inpatient or out-patient basis. We refer to treatment of mental health when the covered person has a mental health disorder. By this, we mean a mental or emotional illness or disorder which generally denotes an illness of the brain with predominant behavioural symptoms; or an illness of the mind or personality, evidenced by abnormal behaviour; or an illness of conduct evidenced by socially deviant behaviour. Mental or Nervous Disorders include: psychosis, depression, schizophrenia, bipolar affective disorder, attitudinal or disciplinary disorders.
5.1.6 Injury from Attempted Suicide/Self-inflicted Injury
Subject to the benefit limit, deductible, co-insurance and co-payment, this is treated as any other eligible medical condition.
Please note: No benefit shall be payable if the covered person has been diagnosed with attention deficit disorders, disruptive behaviour disorders, or pervasive development disorders, prior to applying the policy.
5.1.7 Alcohol and Substance Abuse
Subject to the benefit limit, deductible, co-insurance and co-payment, this is treated as any other eligible medical condition but it must be treated in hospital or in a medical practitioner’s office and we will pay for the following benefits:
a) in-patient treatment in a hospital for alcohol and substance abuse detoxification; and
b) out-patient treatment in a medical practitioner’s office for alcohol and substance abuse.
By alcohol abuse, we refer to any pattern or habitual misuse of alcohol that causes impairment in any social or occupational functioning(s); failure to fulfil any major occupation, schoolwork, or responsibilities at home that produces physiological dependency and/or an adaptive state associated with a withdrawal evidenced by physical symptoms.
By substance abuse, we refer to any pattern or habitual misuse of drug(s) or smoking or nicotine dependence that causes impairment in any social or occupational functioning(s); failure to fulfil any major occupation, schoolwork, or responsibilities at home that produces physiological dependency and/or an adaptive state associated with a withdrawal evidenced by physical symptoms
Please note: Institutions specialising in or primary treating substance use disorder or addiction are not covered. We also do not pay for products that treat or prevent alcohol or substance addiction or dependence, whether or not it is prescribed by a medical practitioner.
5.1.8 Acquired Immune Deficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV) and Sexually Transmitted Diseases (STD)
Subject to the benefit limit, deductible, co-insurance and co-payment, this is treated as any other eligible medical condition. We will pay for this benefit provided the signs or symptoms for AIDS, HIV or STD are present after the covered person is covered with us.
Out-patient treatment benefits:
The table below states the co-payment applicable to general practitioner, specialist and the place of
treatment (USA in-network, USA out-network and outside USA), per out-patient visit.
We will waive the co-payment when treatment is rendered at the University Health Center or Student Health Centre.
Out-patient treatment benefits | USA (In-Network) | USA (Out-of- Network) | Outside USA |
Co-Payment per visit by the covered person to a General Practitioner who is not from the University Student Centre | USD 25 | USD 50 | USD 25 |
Co-Payment per visit by the covered person to a Specialist who is not from the University Student Centre | USD 50 | USD 100 | USD 50 |
5.1.9 Out-patient Treatment
Subject to the benefit limit, deductible, co-insurance and co-payment, we will pay for:
a) medical practitioner’s charges for consultations,
b) diagnostic procedures,
c) computerized tomography, magnetic resonance imaging, positron emission tomography and gait scans received as an out-patient
d) radiotherapy and/or chemotherapy received as an out-patient,
e) kidney dialysis received as an out-patient,
f) out-patient surgical procedures
5.1.10 Out-patient Prescription Drugs
This benefit pays for prescribed drugs by a medical practitioner for the treatment of an eligible medical condition, and the eligible expenses are subjected to the benefit limit, deductible and co- insurance. This shall exclude the following: Replacement of lost, stolen, damaged, expired or otherwise compromised drugs, supplies that are over-the-counter products, products without prescriptions, and supports or brace appliances.
Please present your membership card to the network pharmacy when the prescription is filled.
In order to be considered for reimbursement, please submit a reimbursement form for the
prescription along with the paid receipt and prescription receipt.
We will not pay for any prescription in excess of the number specified by the physician, or any refill dispensed after ninety (90) days from the physician’s original order
Please note: Pre-certification for any prescribed drug or other medication required for more than thirty (30) days is compulsory.
5.1.11 Emergency Out-patient Treatment
We will pay for this benefit if it is for emergency treatment provided on an out-patient basis. The deductible will not apply if the emergency treatment subsequent lead to an eligible in-patient treatment. The co-insurance and co-payment will continue to apply.
5.1.12 Therapeutic Services
Subject to the benefit limit, deductible and co-insurance, this benefit is limited to USD 50 per visit and a maximum of thirty (30) days per covered person per policy year.
We will pay for occupational therapy, physical therapy and speech therapy given by an occupational therapist, physiotherapist or speech therapist respectively for an eligible medical condition, provided on an out-patient basis.
Treatment given by occupational therapist, or speech therapist, who is recognized by us and registered to practice where the eligible treatment is given, and it must be under the medical supervision of a medical practitioner. Medical supervision means that the reason for referral, where applicable, has been initiated by the medical practitioner who has defined a diagnosis.
There must be a clear treatment plan from the occupational therapist, physiotherapist or speech therapist with an end point and expected outcome.
5.1.13 Acupuncture and Homeopathy
Subject to the benefit limit, deductible and co-insurance, this benefit is limited to USD 500 per covered person per policy year. We will pay for consultations and alternative treatment provided on an out-patient basis, and the treatment is given by a qualified acupuncturist or homeopath who is recognized by us and registered to practice in the country where acupuncture or homeopathy is given in.
Within this benefit and up to the limit applicable to the covered person’s plan, we will also pay for vitamins or supplements or traditional Chinese medicine when such are prescribed by the acupuncturist or homeopath.
There must also be a clear treatment plan from the acupuncturist and homeopath with an end point and expected outcome.
For avoidance of doubt, no benefit shall be payable for any alternative treatment arising from any in- patient treatment, day-care treatment or diagnostic procedures.
Maternity benefits:
5.1.14 Maternity Care for covered pregnancy
Subject to the benefit limit, deductible, co-insurance and co-payment, we will pay for the following benefits from the policy effective date with no waiting period, provided the conception of the child is conceived after the covered person is covered with us:
a) cost of pre-natal routine care ,
b) pre- and post-natal complications treated in a hospital or in a medical practitioner’s office. The list of eligible pre- and post- natal complications include the following:
• Antiphospholipid syndrome,
• Cervical incompetence,
• Ectopic pregnancy,
• Gestational diabetes,
• Hydatidiform mole – molar pregnancy,
• Hyperemesis gravidarum,
• Obstetric cholestasis,
• Pre-eclampsia / Eclampsia,
• Rhesus (RH) factor,
• Threatened miscarriage,
• Post partum haemorrhage,
• Retained placental membrane,
c) cost of delivery of the baby either in the hospital or by a registered midwife in the hospital or at home.
For birth through elective or non-medically necessary caesarean section, we will pay for the delivery costs up to the costs of a normal delivery. If we are not able to determine that a caesarean section is medically necessary we will consider it as non-medically necessary,
d) post-natal routine care up to ninety (90) days following the delivery of the baby,
e) post-natal complications up to ninety (90) days following the delivery of the baby,
f) investigation and treatment to the cause of infertility.
This benefit will not be applicable to dependent child(ren).
5.1.15 Contraception
Subject to the benefit limit, we will pay for female voluntary sterilization procedures and related services and supplies including but not limited to tubal ligation and sterilization implants. We will only pay for the procedure itself and this will not include any follow up treatment or complications arising from this voluntary sterilization.
We will also pay for contraceptive drugs or devices that are prescribed by a medical practitioner, and are used for the purpose of Family Planning are covered. We only pay for these items, prescribed by a medical practitioner, and approved by Food and Drug Administration (FDA) or generic equivalents approved as substitutes by the FDA: birth control patch, birth control pills, birth control rings, birth control shot, cervical cap, contraceptive implant, diaphragm, IUD and permanent contraception method for women such as tubal ligation (limited to one per lifetime).
This benefit is not subject to the deductible or co-insurance.
5.1.16 Abortion
Subject to the benefit limit, deductible, co-insurance and co-payment, this benefit is limited to USD 500 per covered person per policy year. We will pay for therapeutic abortion prescribed by a medical practitioner or intentional termination of a pregnancy before the fetus can live independently (defined as a maximum of twenty-eight (28) weeks of pregnancy) performed by a medical practitioner. Should there be complications of such therapeutic abortion or intentional termination of a pregnancy requiring hospital confinement, hospitalisation charges will be eligible. This benefit is limited to USD 500 per covered person per policy year.
Elective Termination of Pregnancy:
Coverage will be provided for one (1) treatment per year for an elective termination of pregnancy. Therapeutic Termination of Pregnancy:
Therapeutic, also known as medically indicated termination, or medically indicated abortion — is only covered in cases where the mother is at risk of death by continuing the pregnancy, or if the fetus has a medical condition which is certain to result in death either before or shortly after birth.
New born benefits:
5.1.17 Premature Birth, Congenital Conditions, Anomalies of the New born
Subject to the benefit limit, deductible, co-insurance and co-payment, we will pay for this benefit when all the following criteria has been met:
a) the insured person, who is the parent of the new born baby, has been covered under StudentCare Exclusive for three hundred and sixty-five (365) days or more when the baby is born
b) the new born baby is added into the insured parent's policy within thirty (30) days from birth; and
c) both insured parent and baby have been continuously covered under the policy and the policy is in force when the treatment is received.
5.1.18 Routine New born Care
Subject to the benefit limit, deductible and co-insurance, we will pay for the covered person’s new born baby, while the new born baby is confined to a hospital immediately after birth, as follows:
a) hospital charges for routine nursery care during the new born baby and the insured parent’s
confinement in the hospital for childbirth, but not more than four (4) days,
b) medical practitioner’s charges for visits to the new born baby in the hospital immediately after birth and consultations but not more than one (1) visit per day.
This benefit is paid under the policy of the covered person (i.e. the insured parent).
Other benefits:
5.1.19 Dental Treatment due to Accident
Subject to the benefit limit, deductible, co-insurance and co-payment, this benefit is limited to USD 300 per natural tooth and a maximum of USD 600 per covered person per policy year. We will pay for the dental treatment caused by an extra-oral impact and is resulted by an accident, and the treatment is given by a dental practitioner. We only pay for dental treatment required following accidental damage to natural teeth and the covered person has been continuously covered under the policy to be covered under this benefit, before the accident happened.
Benefit is not payable if:
a) the injury was caused by any form of eating or drinking, even if it contains a foreign body or
b) the damage was caused by normal wear and tear, or
c) the injury was caused when engaging in any sporting activities other than activities relating to intercollegiate, interscholastic, intramural, club sports, etc. or
d) the damage was caused by tooth brushing or any other oral hygiene procedure, or
e) the injury was caused by any means other than extra-oral impact, or
f) the damage is not apparent within seven (7) days of the impact which caused the injury, or
g) the costs are incurred more than eighteen (18) months after the date of first onset of the
accidental injury
5.1.20 Paediatric Dental and Vision
Paediatric is defined as under the age of nineteen (19), and this benefit is only applicable to the
dependent child.
Subject to the co-insurance (for out-of-network), we will pay for:
a) out-patient routine dental examination, extraction, fillings, scaling/polishing, x-xxx, sealant, fluoride treatment, root canal treatment, implants, bridgework, crowns, treatment of gum disease, dentures, inlays and outlays, limited to two (2) visits per policy year
b) Vision examination performed at a vision care center by an optometrist for the purpose of determining the need for corrective lenses, and if needed to provide a prescription. We will only pay for one (1) vision examination in a policy year.
This benefit include eye glasses or contact lenses for the dependent child under nineteen (19) years old up to US$ 150 per policy year for one pair of standard frames or contact lenses when medically necessary and must provide a dioptre.
5.1.21 Health Screening/Preventive Care
Subject to the benefit limit, we will only pay for routine examination for the following listed items. We refer to routine examination as the examination of the physical body by a medical practitioner or a healthcare provider for the preventive or informative purpose only. It is not for the purpose of diagnosis, treatment(s) of any previously manifested, symptomatic, and/or any diagnosed known illness or injury.
The list of items that we will pay are as follows:
a) Alcohol misuse screening and counselling
c) Cholesterol screening for adults of certain ages or at higher risk (for men age thirty-five (35) and older, women age forty-five (45) and older and younger adults at higher risk)
d) Diabetes (Type 2) screening for adults with high blood pressure
e) Diet counselling for adults at higher risk for chronic disease
f) HIV screening for everyone ages fifteen (15) to sixty-five (65), and other ages at increased risk
g) Immunization vaccines for adults — doses, recommended ages, and recommended populations vary:
h) Sexually transmitted infection (STI) prevention counselling for adults at higher risk
i) Syphilis screening for adults at higher risk
This benefit is not subject to the deductible or co-insurance.
5.1.22 Extended Care / In-patient Clinics /In-patient Rehabilitation
Subject to the benefit limit, deductible and co-insurance, we will pay for in-patient treatment for extended care/in-patient clinics/ rehabilitation, up to maximum of thirty (30) days per covered person per policy year, when:
a) the facility must be licensed in the State in which they operate in; and
b) it is carried out by a medical practitioner specialising in nursing care and/or rehabilitation; and
c) it is carried out in an extended care facilities, in-patient clinic and rehabilitation hospital or unit which is recognized by us; and
d) the treatment could not be carried out on an out-patient basis, and
e) the costs have been agreed, in writing by us before the in-patient treatment in such facility begins, and
f) all treatment plans are prescribed by the medical practitioner for the patient's illness or injury.
g) following discharge from a hospital.
Please note, for clarity: Extended care/ In-patient Clinics /In-patient Rehabilitation should not include facility for rest, aged, alcohol and substance abuse, custodial care, and/or mental health disorders.
5.1.23 Hospice and palliative care
Subject to the benefit limit, deductible and co-insurance, this benefit is payable up to lifetime maximum of thirty (30) days for in-patient, in aggregate, for all related and associated conditions. This benefit becomes available when the covered person is admitted to a specialist palliative care centre or hospice, recognized by us, following diagnosis by, and written confirmation (including medical evidence) from a medical practitioner that the covered person is suffering from an eligible terminal medical condition and its associated medical conditions.
Once the covered person is admitted, all costs of care and any treatment related to an eligible terminal medical condition will be taken from this benefit and may not be claimed from any other benefit applicable to this plan. Any eligible medical conditions not related to the covered person’s terminal medical condition will be covered under the covered person normal plan benefits. We reserve the right to determine, on the advice of our medical panel, whether a medical condition is, or is not, related to the terminal medical condition.
The covered person must maintain the same level of cover throughout the palliative or hospice care admission. This means that, if the period of palliative or hospice care falls across a policy anniversary, you must pay the premium for the subsequent policy year or the benefit will cease at the policy anniversary. In the event that the costs of the covered person’s admission reaches the limit shown in this benefit no further benefit will be payable. Once the limit of this benefit is reached no benefit of any kind will be payable in respect of any medical condition for which palliative and/or hospice care has been received.
5.1.24 Home Health Nurse / Skilled Nursing / In-Home Nurse / Private Duty Nurse
Subject to the benefit limit, deductible and co-insurance, this benefit is limited to a maximum limit of one hundred (100) days per covered person per policy year.
We will pay the home nursing charges of a nurse at the covered person’s home and only when all the following conditions are met:
a) after the covered person’s discharge from hospital which he/she had been warded in the
intensive care unit for an eligible medical condition, and
b) agreed in writing by us beforehand that it is medically necessary and appropriate, and
c) it is prescribed by the treating medical practitioner for the continued treatment for the eligible
medical condition which the covered person was hospitalised for, and
d) when such services are essential for medical as distinct from domestic reasons.
For avoidance of doubt, the charges refer to the fees for the service of the nurse incurred for nursing at home.
For terminal medical condition, this benefit is only payable under ‘Hospice and Palliative Care’ and
subject to the limitations applicable to that benefit.
5.1.25 Intercollegiate, interscholastic, intramural, club sports
Subject to the benefit limit, deductible and co-insurance, this benefit is limited to a USD 1500 per covered person per policy year. We will pay for expenses incurred while sustaining an illness or injury by taking part in activities organised by the school, such as intercollegiate, interscholastic, intramural, club sports, etc. subject to the following exclusions (y) and (z):
(y)Any costs incurred as a result of engaging in or training for any sport for which the covered person receives a salary or monetary reimbursement, including grants or sponsorship (unless the covered person receives travel costs only).
(z) Treatment of injuries sustained from base jumping, cliff diving, flying in an unlicensed aircraft or as a learner, martial arts, free climbing, mountaineering with or without ropes, scuba diving to a depth of more than ten (10) meters, trekking to a height of over two thousand and five hundred (2,500) meters, bungee jumping, canyoning, hang-gliding, paragliding or microlighting, parachuting, potholing, skiing off piste or any other winter sports activity carried out off piste.
For avoidance of doubt, accidental damage to natural teeth caused by taking part in extra co-curricular activities organised by the school will not be covered under this benefit, such expenses shall be covered under ‘Dental Treatment due to accident’ benefit.
5.1.26 Durable Medical Equipment
Subject to the benefit limit, deductible, co-insurance and co-payment, we will pay for instruments or devices or durable medical equipment which is prescribed by the medical practitioner as a medically necessary aid to the function or capacity such as, and limited to compression stockings, hearing aids, speaking aids (electronic larynx), wheelchairs, crutches, corrective splint and orthopaedic supports
5.1.27 Local Road Ambulance
Subject to the deductible, we will pay for a local road ambulance for medically necessary emergency transport to or between hospitals. The medical practitioner of the covered person will determine if this is medically essential. We reserve the right to ultimately determine whether such transportation
was medically appropriate. (This does not form part of ‘Emergency Medical Evacuation and Repatriation’).
5.1.28 Pre-existing Condition
We will pay for expenses incurred in respect of, or arising from any pre-existing conditions from the policy effective date with no waiting period, provided:
a) all the underwriting questions in the StudentCare Exclusive application form did not require the policyholder or the covered person to answer ‘Yes’ at application; or
b) there is no non-disclosure of material facts by the policyholder or the covered person; or
c) the covered person has not experienced symptoms or should reasonably in our opinion have known about; or
d) for which the covered person has experienced symptoms even if the covered person has not consulted a medical practitioner
International Emergency Medical Assistance (IEMA)
The benefits and services under Section 5.1.29 to 5.1.31 are provided by our chosen international assistance company who acts for us.
We shall not be responsible or liable in any way in the event of any failure by the international assistance company to render the services or any negligence (wilful or otherwise) on the part of the international assistance company in rendering these services.
The evacuation or repatriation service is available when the covered person contacts the international assistance company:
a) All cases must be assessed by us, be deemed necessary for emergency evacuation or repatriation and all arrangements must be made by our chosen international assistance company in order to ensure that related costs are covered.
b) If the covered person (or his family member) makes his own arrangements, the costs will not be covered. The entitlement to the stated services does not mean that the covered person’s treatment following emergency evacuation or repatriation will be eligible for benefit. Any such treatment will be subject to the terms and conditions of your plan.
c) Exclusions apply to your cover for emergency evacuation or repatriation.
You are not covered for emergency evacuation or repatriation if any of the following apply:
• the medical condition does not need immediate emergency in-patient treatment
• the medical condition does not prevent you from travelling or working
• the medical condition is directly or indirectly caused by a deliberately self-inflicted injury, suicide or an attempt at suicide
• the medical condition is in any way connected with alcohol abuse, drug abuse or substance abuse
• the medical condition is a result of engaging in or training for any sport for which you receive a salary or monetary reimbursement, including grants or sponsorship (unless you only receive travel costs)
• the medical condition is a result of base jumping, cliff diving, flying in an unlicensed aircraft or as a learner, martial arts, free climbing, mountaineering with or without ropes, scuba diving to a depth of more than ten (10) metres, trekking to a height of over two thousand and five hundred (2,500) metres, bungee jumping, canyoning, hang-gliding, paragliding or microlighting, parachuting, potholing, skiing off piste or any other winter sports activity carried out off piste
• the evacuation would involve moving you from a ship, oil-rig platform or similar off-shore location
• we have not approved the evacuation or repatriation first
• we have not been told about the medical condition within thirty (30) days of the condition becoming an emergency (unless this was not reasonably possible)
• the medical condition is a result of nuclear, biological or chemical contamination, war (whether declared or not), act of foreign enemy, invasion, civil war, riot, rebellion, insurrection, revolution, overthrow of a legally constituted government, explosions of war weapons or any event similar to one of those listed
• the emergency occurs when you are on a leisure trip to a destination to which the Greater China or the U.S. Department of State either advises against all travel, or advises against all travel on holiday or non-essential business.
5.1.29 Emergency Medical Evacuation and Repatriation
a) We will cover the costs of emergency evacuation if:
• you are, or need to be, admitted as an emergency in-patient, and
• our appointed doctor and the treating doctor believe your current or nearest medical facilities are not able to provide the treatment you need.
We will cover the costs of repatriating you if we have agreed to cover your emergency evacuation. We will not cover the cost of evacuating or repatriating you if you decide to travel elsewhere for
treatment and we believe the nearest medical facilities are adequate for your treatment. This includes if you decide you want to travel back to the country where you normally live for your treatment.
b) How Emergency Medical Evacuation and Repatriation cover works?
If you are admitted as an emergency in-patient and you or the treating doctor believe that the local medical facilities are not adequate to treat you, ask somebody to call our emergency number.
We will appoint a doctor who will be able to assess the facilities and the evacuation or repatriation
service detailed at the beginning of this section will apply.
c) What costs we will cover?
If the doctor we appoint decides that the facilities are not adequate to treat you, we will cover the reasonable costs of either:
• evacuating you to a suitable medical facility for treatment in the country you are in; or
• evacuating you to a suitable medical facility in a different country for treatment.
When you are discharged from the medical facility you were evacuated to, we will cover the costs of repatriating you to one of the following:
• the place or country where you normally live (the country where the covered person lives or intends to live for most of the year.),
• a country that you hold a passport for.
We will cover these costs so long as we have agreed the method of transport to be used, and date and time of your evacuation or repatriation before it takes place.
We will also cover the cost of any necessary treatment given to you by our chosen evacuation agency while they are moving you.
d) What will happen to my travel ticket?
Any unused portion of the travel tickets belonging to you or anyone that we evacuate with you will immediately become our property. You must give the tickets to us.
e) Can you choose to travel to a particular country for treatment?
You can choose to go to a particular country for treatment, but we will not cover the cost of travelling to that country. Once you are in that country, the terms of your policy apply as normal.
5.1.30 Repatriation of Remains
a) Repatriation following death
If you die outside a country that you hold a passport for, we will cover the cost of transporting your remains (i.e. body or ashes) back to a port or airport in:
• the country where you normally live (the country where the covered person lives or intends to live for most of the year.),
• a country you hold a passport for.
5.1.31 Emergency Reunion
This benefit is limited to USD 5,000 per covered person per policy year and a lifetime maximum of fifteen (15) days. Any arrangement for any air transport will be limited to the cost of one economy class return airfare.
a) Will other members of my family or friends be able to travel with me?
If the covered person who needs to be evacuated or repatriated is under eighteen (18), we will cover the additional reasonable and necessary transport and accommodation costs for someone, aged eighteen (18) or over, to accompany them on their journey. If the member who needs to be evacuated
or repatriated is over eighteen (18), we may agree to cover these costs if we believe it is medically appropriate.
Once the covered person reaches their evacuation destination, we will not cover the accompanying
person’s further costs.
b) What cover do you have if a family member covered by the policy is evacuated or repatriated? Your cover depends on whether they are evacuated or repatriated either from the location where you
both normally live or whether you are travelling together at the time.
If you are travelling away from home with a family member who is covered by the policy and they are evacuated or repatriated, we will pay for your additional reasonable and necessary transport and accommodation costs that result from the evacuation or repatriation. We will do this if it is medically appropriate for you to travel with the family member.
If you are both at the location where you normally live and they have to be evacuated or repatriated from that location, we will pay for your additional reasonable and necessary transport costs that result from the evacuation or repatriation. We will do this if it is medically appropriate for you to travel with the family member. We will not cover your accommodation costs.
5.1.32 Accidental Death or Permanent Dismemberment
Subject to the lifetime maximum, benefit limit, deductible, co-insurance and co-payment, we will pay for Death or Permanent Disablement caused by an accident to a covered person for such Death or Permanent Disablement occurring after his/her Commencement Date:
(a) Death - the total sum assured in case of death if We have not paid for any sum assured for Permanent Disablement listed in (b) , or
(b) Permanent Disablement - the total sum assured which resulted in one of the following Permanent Disablement:
• Total and irrevocable loss of sight of both eyes, or
• Complete and permanent deafness of both ears, or
• Removal of lower jaw, or
• Loss of both arms or both hands, or
• Loss of both legs or both feet, or
• Loss of one (1) arm and one (1) leg, or
• Loss of one (1) arm and one (1) foot, or
• Loss of one (1) hand and one (1) foot, or
• Loss of one (1) hand and one (1) leg, or
• Total paralysis of four (4) limbs.
For avoidance of doubt, the exclusions and limitations of this Policy will apply to this benefit at all times and also, no benefit shall be payable for accidental death or permanent dismemberment due to mental health disorder / alcohol and substance abuse / suicide/ attempted suicide or self-inflicted injury.
Section 6 – Exclusions and limitations
6.1 The following tests, investigations, treatments, items, conditions, activities and their related or consequential expenses are excluded from this policy and we shall not be liable for:
a) any treatment which offers temporary relief of symptoms rather than dealing with the underlying
medical condition;
Please note: we will not refuse to pay for other forms of curative treatment after an effective treatment has been recommended by the treating medical practitioner. However, we will not pay for treatment that is only offering temporary relief of symptoms where there is no cure or where your covered person refuses to undergo an effective and available treatment for whatsoever reasons but we will pay for temporary relief of symptoms when such treatment falls under “Hospice and Palliative Care” benefit;
b) treatment begun, or for which the need had arisen, during the first ninety (90) days after birth for any child conceived by artificial means or any form of assisted conception;
c) treatment directly related to surrogacy whether the covered person is acting as surrogate, or is the intended parent;
d) foetal surgery. By this we mean treatment given or undertaken on a foetus while in the womb;
e) treatment of impotence or varicocele or any of their consequence;
f) treatment of, or related to, sexual dysfunction or any consequence of it;
g) gender re-assignment operations or any other surgical or medical treatment including psychotherapy or similar services which arise from, or are directly or indirectly associated with gender re-assignment;
h) costs incurred for the male or female reversal of voluntary sterilizations, including related follow- up care and treatment of complications of such procedures.
i) treatment of obesity (Body Mass Index (BMI) equal to thirty (30) or above) or any medical condition
which arises from, or is related to, obesity in any way;
j) costs incurred for, or related to, any kind of bariatric surgery, regardless of the reason the surgery is needed. This includes, but is not limited to, the fitting of a gastric band or creation of a gastric sleeve;
k) the removal of fat or surplus tissue from any part of the body whether or not it is need for medical or psychological reasons (such as, but not limited to, breast reduction);
l) appetite suppressant(s);
m) the costs of collecting donor organs or tissue or any administration costs (such as, but limited to, the cost of donor search) even if such transplants are allowed by the terms of this policy;
n) parenting or other teaching classes such as, but not limited to ante-natal classes; all types of classes/courses/programs such as, but not limited to, cessation of alcohol, smoking, drugs or substance;
o) treatment provided to the covered person by the policyholder, a business partner, the agent or a family member of the covered person or the policyholder, or self-treatment by the covered person, including the prescription of drugs;
p) any treatment to correct refractive defects of the eyes such as long or short-sightedness or astigmatism; laser/lasik eye surgery;
q) all types of learning disorders, educational problems, behavioural problems, physical development or psychological development, including assessment or grading of such problems. This includes, but is not limited to, problems such as dyslexia, dyspraxia, autistic spectrum disorder, attention deficit hyperactivity disorder (ADHD) and speech or language problems;
r) any costs incurred for treatment of covered person who specialise in the mental health care field; and who receive treatment as a part of their training in that field;
s) preventive (i.e. prophylactic) treatment or for tests to establish whether a medical condition is present when there are no apparent symptoms;
t) any costs incurred as a consequence of treatment that is not eligible under the policy, including increased treatment costs;
u) treatment to relieve symptoms commonly associated with any bodily change arising from any physiological or natural cause such as aging, menopause, or puberty and which is not due to any underlying disease, illness or injury;
v) vaccination unless provided for under Section 5.1.21;
w) the costs of providing or fitting any external prosthesis or orthosis or appliance or medical aids;
x) dental implants; orthodontics, periodontics, endodontics, preventative dentistry, and general dental care including fillings, no matter who gives the treatment unless allowed for by the covered person’s plan stated in the benefits table;
y) treatment incurred as a result of engaging in or training for any sport for which the covered person receives a salary or monetary reimbursement, including grants or sponsorship (unless the covered person receives travel costs only);
z) treatment of injuries sustained from base jumping, cliff diving, flying in an unlicensed aircraft or as a learner, martial arts, free climbing, mountaineering with or without ropes, scuba diving to a depth of more than ten (10) meters, trekking to a height of over two thousand and five hundred (2,500) meters, bungee jumping, canyoning, hang gliding, paragliding or microlighting, parachuting, potholing, skiing off piste or any other winter sports activity carried out off piste;
aa) any charges which is incurred for social or domestic reasons (such as travel or home help costs) or for reasons which are not directly connected with treatment;
bb) aquatic therapy or any charges from health hydros, spas, nature cure clinics, fitness centres or any similar place, even if it is registered as a hospital, or even if treatment is provided by a registered medical practitioner;
cc) any administration costs or reports of any kind or any other charges of a non-medical nature in connection with the provision and/or performance of medical supplies and/or services; telephone calls;
dd) all bank or credit charges when the claims payment is made in a currency other than USD or Chinese Yuan Renminbi; foreign exchange losses;
ee) claims for any supplements or substances which are available naturally. This includes, but is not limited to: vitamins, minerals, and organic substances;
ff) nutritional supplements including but not limited to special infant formula and cosmetic products even if medically recommended or prescribed or acknowledged as having therapeutic effects;
gg) cryopreservation, or harvesting or storage of stem cells as a preventive measure against possible disease/illness/injury;
hh) treatment which is not considered medically necessary or which may be considered as a matter of personal choice or which is not reasonable and customary;
ii) home visits such as, but not limited to, medical practitioner, health professionals, except for Home Health Nurse / Skilled Nursing / In-Home Nurse / Private Duty Nurse described under Section 5.1.24;
jj) in-patient treatment for a medical condition which can be properly treated as an out-patient;
kk) genetic tests, nor any counselling made necessary following genetic tests, even when those tests are undertaken to establish whether or not the covered person may be genetically disposed to the development of a medical condition in the future. This is because such tests are carried out for purposes of establishing whether a medical condition might develop and not for the treatment of a medical condition;
ll) standard toiletries such as, but not limited to, shampoos, soaps, toothpastes, mouthwash, lotions, moisturiser, cleansers, shower gels; contraceptives (unless provided for under Section 5.1.15), or any over the counter drugs or medicine without prescriptions;
mm) all types of sleep disorder including, but not limited to, snoring, insomnia, obstructive sleep apnoea, or sleep study tests;
Please note: we will not refuse to pay for surgery for sleep apnoea and an initial sleep study test (maximum one sleep study test per covered person’s lifetime) if all of the following criteria are met:
(i) the covered person has been prescribed other forms of treatment by a specialist but all these treatment have not been successful to treat the covered person’s obstructive sleep apnoea,
(ii) the specialist confirmed that the surgery is medically necessary otherwise, it is life threatening,
(iii) at the time of surgery for the obstructive sleep apnoea, the covered person has been insured with us consecutively for more than two (2) policy years on this policy, and
(iv) the surgery has been approved by us in advance.
nn) investigations or treatment of loss of hair and any hair replacement or transplant; oo) all forms of acne;
pp) ear or body piercing and tattooing or treatment needed as a result of any of these;
qq) treatment whilst staying in a hospital for more than ninety (90) continuous days for permanent neurological damage or if the covered person is in a persistent vegetative state. We define persistent vegetative state as a condition of profound no responsiveness, with no sign of awareness or
consciousness or a functioning mind, even if the person can open their eyes and breathe unaided, and the person does not respond to stimuli such as calling their name, or touching.
rr) any costs incurred when the covered person is acting beyond the scope of his/her/its legal authority.
ss) any cost or service or treatment incurred in a country that is sanctioned by the Greater China, United Nations (UN) and / or United States of America (USA) and / or European Union (EU) at the time of treatment. Details of these countries can be obtained by calling our Customer Service Team.
Special terms apply in the following cases:
6.2 The following tests, investigations, treatments, items, conditions, activities and their related or consequential expenses are excluded from this policy and we shall not be liable for:
a) cosmetic (aesthetic) surgery or treatment;
b) any treatment which relates to or is needed because of previous cosmetic treatment or reconstructive surgery;
c) special nursing in hospital unless we have agreed in writing or by beforehand that it is necessary and appropriate;
d) the use of any drug which has not been established as being effective or which is experimental or within clinical trials. This means they must be licensed by the European Medicines Agency if the covered person is receiving treatment in Europe, or the US Food and Drug Administration (FDA) if the covered person is receiving treatment anywhere else in the world, and be used within the terms of that license. However we will pay if, before the treatment begins, it is established that the treatment is recognized as appropriate by an authoritative medical body and we have agreed in writing with the medical practitioner, what the fees will be;
e) treatment which has not been established as being effective or which is experimental. For established treatment, this means procedures and practices that have undergone appropriate clinical trial and assessment, sufficiently evidenced in published medical journals for specific purposes to be considered proven safe and effective therapies.
6.3 We will not pay for any treatment, or for Emergency Medical Evacuation and Repatriation, if they are needed as a result of nuclear contamination, biological contamination or chemical contamination, while engaging in or taking part in war (whether declared or not), act of foreign enemy, illegal or criminal activities, invasion, civil war, riot, rebellion, insurrection, revolution, overthrow of a legally constituted government, explosions of war weapons or any event similar to one of those listed. This includes treatment needed as a result of the covered person exposing himself/herself to needless peril, such as going to a place of unrest as an active onlooker or a spectator.
Please note, for clarity: There is cover for treatment required as a result of a terrorist act providing that terrorist act does not result in nuclear, biological or chemical contamination
6.4 We will not pay benefits for:
a) any treatment needed as a result of work related accident or injury where the cost of such treatment is recoverable under a Workman's Compensation policy or similar cover required by Government Act prevailing in the country where the work related accident or injury took place or elsewhere at the time of injury or accident. We may, at our absolute discretion, consider the claims
provided we are able to recover such costs. You and/or the covered person must advise us if any claim is work related.
b) treatment required as a result of negligence or malpractice of a third party. You and/or the covered person must take all reasonable steps to recover the loss from the third party or third party insurer.
We may, at our absolute discretion, consider the claims provided we are able to recover such costs. You and/or the covered person must advise us if any claim is work related or resulted from the negligence or malpractice of a third party.
6.5 We reserve the right to not pay benefits if we have not received a properly completed medical claims form and original invoices within two (2) years of the treatment being received.
Section 7 – General Conditions
7.1 Effective Date
Coverage is effective only when we have received the completed application form and we have confirmed the coverage in writing for the covered person, with the full premium received.
The effective date will be stated on the certificate of insurance, we allow a maximum period of sixty
(60) days, from the effective date of the policy, for application submission.
7.2 Renewal upon payment of premium
7.2.1 The period of insurance is one (1) year. Prior to the end of any policy year we will write to the policyholder to advise on what terms the policy will continue, provided the policy you are on is still available. If we do not hear from the policyholder in response we will renew the policy on the new terms. Where you have opted to pay premium by Direct Debit, continuous credit card payments or other payment method, we may continue to collect premium by such method for the new policy year. Please note that if we do not receive the premium, you will not be covered. If the policy is terminated due to non-payment of premium, you should reapply for insurance cover under this policy.
7.2.2 Premium rates are not guaranteed and the premium payable at policy anniversary shall be determined at each policy anniversary based on the attained age of each covered person, the premium rates then in effect, and any other factors which may materially affect the risks insured. The policy will be renewed for another policy year when the required premium is paid on or before the renewal date, or before the premium grace period.
The required renewal premium for the covered person whose insurance is renewed will be calculated at the rate of premium applicable on the renewal date to the age of the person insured on the renewal date.
The Company may amend the terms and conditions and/or the rates of premium at renewal, and the person insured will be informed of the amendments at least thirty (30) days before the renewal date at which time the amendments will apply.
7.3 Termination of the Policy
Subject to the other terms of this policy, this policy shall automatically terminate on the earliest occurrence of any of the following:
a) the last day (at 11.59pm Beijing Time, CST) of the coverage period where the premium was paid,
b) when the insured person is no longer holding a USA F-1 or J-1 visa
c) when the waiver of the US University is not approved, we will refund the full premium provided we are informed within forty-five (45) days from the policy commencement date and there is no claim incurred during this period,
d) when the person insured (i.e. the international student) dies,
e) when there is a breach of any regulation and/or law and/or economic sanctions whereby the Benefit Provisions under this policy will become illegal.
f) when you terminate the policy by submitting a written notice of termination to us. The policy will be treated as terminated with effect from the request date or on the date advised in the written notice, subject to no back date from the date of request.
Please note: For scenario (f), no premium refund will be made, whether or not a claim has been incurred under the policy. We will only allow termination with refund if there is a valid reason for you to terminate the policy, provided there is no claim incurred, and supporting document must be provided for our consideration. Please refer to the short period scale refund under 7.15 for further information on the refund percentage.
If the policy has been terminated due to non-payment of premium, the applicant must reapply as a new application, and the application will be subject to our approval.
7.4 Grace Period
A grace period of thirty (30) days, will be allowed for renewal premium payment. During this period, this policy will continue to be in force, but if any sum becomes payable by us during this period, such amount will only be paid after you have paid the total premium due by the end of the grace period, if you fail to make the premium payment by the end of the grace period, the policy will automatically terminate. If the policy is terminated due to non-payment of premium, you should reapply as a new application, and the application shall be subject to approval.
7.5 Compliance with the Policy Terms
Our liability under this policy will be conditional upon each covered person complying with its terms and conditions.
7.6 Deletion of dependent
The policyholder may delete the dependent by submitting a written notice to us and the deletion date will be effective from the date of request or the date as advised by the policyholder in the written notice, subject to no back date from the date of request.
For deletion of dependent, no premium refund will be made if there is any claims incurred under the policy. The membership cards issued to the dependent being removed from the policy must be returned to us.
7.7 Change of Risk
The policyholder must inform the Company as soon as reasonably possible, of any changes related to
covered person’s eligibility criteria or of any other material changes that affect information given in
connection with the application for coverage under this policy. The Company reserves the right to alter the policy terms or cancel coverage for a covered person following a change of risk.
7.8 Fraudulent/Unfounded Claims
You must make sure that whenever you or a covered person is required to provide us true, accurate and complete information.
If you or a covered person makes, or attempts to make, any dishonest claim, we reserve the right to:
(i) refuse to make any claims payment; or
(ii) refuse to renew the policy; or
(iii) cancel the policy.
If any claim under this policy is in any respect fraudulent or unfounded, all benefits paid and/or payable in relation to that claim shall be forfeited and, if appropriate, recoverable. The policy may be voided immediately and if we have already made benefit payments, we can recover these sums and refund premium without interest.
7.9 Settlement of Claims
All paid claims will be settled in either USD or Chinese Xxxx Xxxxxxxx. If the covered person paid for treatment, or receives a bill for covered services in a currency other than currency we reimbursed, including bills sent directly to the Company or its Claims Administrator, such payments and bills shall be converted to currency at the exchange rate in effect at the time such service was rendered. The exchange rate will be determined by the insurer acting reasonably.
7.10 Waiver
Waiver by the Company of any term or condition of this policy will not prevent us from relying on such term or condition thereafter.
7.11 Denial of Liability
Neither the insurer nor the policyholder is responsible for the quality of care received from any institution or individual. This policy does not give the covered person any claim, right or cause of action against us or policyholder based on an act of omission or commission of a hospital, medical practitioner or other provider of care or service.
7.12 Co-operation
You or the covered person or his/her representatives shall co-operate fully with us and our medical team (including the independent appointed medical practitioner) and you, the covered person or his/her representatives will fully and faithfully disclose all material facts and matters which you and/or the covered person knows or ought to know and will, upon request, execute any document to empower us to obtain the relevant information, at your or the covered person’s expense from any medical practitioner or hospital or clinic or other source.
7.13 Co-ordination of Benefits
The policy will not provide compensation cover other than on a proportionate basis, this policy will cover the eligible unpaid balances, deductible and those eligible medical expenses not covered by other insurance, if you or the covered person has any other insurance in force or is entitled to indemnity from any other source in respect of the same injury or illness.
This policy is not intended for anyone to receive a greater benefit than the actual medical expenses incurred, the amount of the benefits payable under this policy will take into account any other insurance health coverage.
7.14 Subrogation
We have full rights of subrogation and may take proceedings in the policyholder’s or covered person’s name, but at our expense, to recover the amount of any payment made under the policy and/or to secure an indemnity from a third party.
7.15 Short Period Scale Refund
Applicable only for Annual Premium Payment Mode only and if there is no claim | |
Period of Coverage during the Policy Year | Refund as percentage of annual premium |
Within 45 days of policy commencement – this is only applicable if waiver of the US is not approved | Full premium refund |
Not exceeding 2 months from effective date | 60% |
Not exceeding 3 months from effective date | 50% |
Not exceeding 4 months from effective date | 40% |
Not exceeding 6 months from effective date | 25% |
More than 6 months from effective date | NIL |
7.16 Other Specific General Conditions
7.16.1 It is hereby declared that as a condition precedent to our liability, the policyholder and the covered person have agreed that any personal information in relation to the policyholder provided by or on behalf of the covered person to us may be held, used and disclosed to enable us or individuals/organizations associated with us or any independent third party (within or outside China) to:
(i) process and assess the covered person’s application or any matter arising from the policy and any other application for insurance cover, and/or
(ii) provide all services under the policy.
7.16.2 You must write and tell us if you (or any covered person) change address. You are acting on behalf of any covered person covered under the policy so we will send all correspondence about the policy to your address.
7.16.3 For the purposes of determining premium payable, the covered person’s age shall be deemed to be his/her attained age, and any premium tables or other material we provide in this connection shall be read accordingly. If the age of the covered person has been misstated and the premium paid as a result thereof is insufficient, any claim payable under this policy shall be prorated based on the ratio of the actual premium paid to the correct premium which should have been charged for the original policy effective date of the covered person. Any excess premium, which may have been paid as a result of such misstatement of age, shall be refunded without interest. If at the correct age, the covered person would not have been eligible for cover under this policy, no benefit shall be payable and the actual premium paid shall be refunded without interest. If a claim has been paid in respect of the covered person who was not eligible for cover under this policy, you are required to repay us the amount of the claim and we reserve the right to off-set any premium paid by you against the amount of the claim.
7.16.4 We shall not be bound to take notice of any trust, charge, lien, assignment or other dealing with or relating to this policy, but the payment by us to the policyholder or covered person, his/her nominee or legal representative, as the case may be, of any compensation or benefit under the policy shall in all cases be an effectual discharge to us.
7.16.5 Only those people listed in the policy schedule are considered covered persons of this policy. All cover applicable to a covered person ends if the policyholder decides to end the cover.
7.17 Currency and the exchange rate
The monetary limits applicable to this policy is expressed in United States Dollar (‘USD’). We only accept Chinese Yuan Renminbi for payment of premium during the application. For renewal premium, we accept USD or Chinese Yuan Renminbi. Reimbursement of claims will be made in USD or Chinese Xxxx Xxxxxxxx.
In the event if there is exchange rate conversion, the exchange rate will be determine by the Company at the prevailing exchange rate on the date the expenses were incurred. (i.e. on the date of discharge from the hospital for in-patient and day-care treatment, or on the date of out-patient treatment.)
7.18 Designation and change of beneficiary
With the consent of the covered person, the policyholder may, at the time of application, designate one or more persons as the beneficiary/beneficiaries. In the case of more than one beneficiaries, the policyholder may determine the priority of the beneficiaries and benefit proportions for the death benefits. If the benefit proportions are not specified, all beneficiaries shall be entitled to an equal share of the death benefits. Where the beneficiary intentionally causes the death, injury, disability or illness to the insurant or attempts to murder the insurant, the beneficiary shall lose the beneficiary right.
With the consent of the covered person, the policyholder may change the beneficiary/beneficiaries with a written notice to the Company. No such change shall be effective unless recorded by the
Company and by endorsement hereto. The Company shall not be responsible for any legal disputes resulting from any change(s) in the beneficiary/beneficiaries.
Death benefits shall be paid to the beneficiary/beneficiaries surviving the deceased covered person. Unless otherwise provided, the death benefits shall be payable to the estate of the covered person if none of the named death beneficiary/beneficiaries survives the covered person.
7.19 Consumer privacy Data protection
The State of China protects the electronic information that can identify the personal identity of citizens and that involves privacy of citizens. No organization or individual may obtain the personal electronic information of citizens by steal or other illegal means, nor sell or illegally provide the personal electronic information of citizens to others.
When collecting or using the personal electronic information of citizens in their business activities, the network service providers and other enterprises and public institutions shall follow the principle of lawfulness, properness and necessity, explicitly disclose their purposes, methods and scopes for collection and use of the information, and, upon consent of the information providers, may collect or use information without violation of the provisions of the laws and regulations and the agreement of both parties.
Where the network service providers and other enterprises and public institutions collect and use the personal electronic information of citizens, they shall disclose the rules for such collection and use.
The network service providers and other enterprises and public institutions as well as their personnel must keep in strict confidence the personal electronic information of citizens collected in their business activities. They shall not divulge, distort or damage such information, or shall not sell or illegally provide the same to others.
7.20 Obligations of The Policyholder and The Covered Person
7.20.1 Once an insurance contract is concluded, the applicant shall pay the premium in accordance with the agreement.
7.20.2 When concluding an insurance contract, if the insurer inquires about the relevant circumstances of the insured subject matter or the insured, the policyholder shall give truthful disclosure. In the event that the policyholder deliberately or due to significant negligence, fails to perform the obligation of truthful disclosure as prescribed in the paragraph so as to materially influence and alter the insurer’s decision as to whether or not to provide the corresponding insurance coverage or to increase the premium rate, the insurer shall have the right to rescind the corresponding insurance contract.
In the event that the policyholder deliberately fails to perform his obligation of truthful disclosure due to significant negligence, which has significant relevant bearing on the occurrence of an insured event, the insurer shall not be liable to indemnify or pay the insurance benefit for such insured event occurring prior to the rescission of this contract and if we have already made benefit payments, we can recover these sums and refund premium without interest.
7.20.3 The policyholder and the covered person shall notify the insurer as soon as they respectively become aware of the occurrence of an event which will result in claim submission. Where they
deliberately or due to significant negligence, fail to inform the insurer in time and thus make it difficult to determine the nature, cause and degree of damage and other circumstances of the insured event, the insurer shall not be liable to indemnify or pay the insurance benefits for the portion that cannot be determined, unless the insurer is aware of or ought to be aware of the occurrence of such insured event in due time through other ways. The agreement above does not include the delays caused by force majeure.
7.21 Right of Recovery
In the event that payment is authorized and/or made by us for expenses that are not covered under this policy, we shall be entitled to recover all sums in respect of any liabilities incurred by us.
7.22 Applicable Law/ Jurisdiction
The formation of this Contract, its validity, interpretation, execution and settlement of disputes in connection herewith shall be governed by the law of China.
Any dispute between the covered person and the insurer arising from or in connection with this Policy shall be settled through friendly negotiations. Where the two parties fail to reach an agreement after negotiation, such dispute shall be submitted to the one of the following entities.
1) China International Economic and Trade Arbitration Commission which shall be conducted in accordance with the Commission’s arbitration rules in effect at the time of applying for arbitration provided that such arbitration shall be governed by the law of China. The arbitral award is final and binding upon both parties；or
2) Courts having jurisdiction for judgment.
The dispute resolution shall be settled and agreed between covered person(s) and the insurer when the insurance contract is executed. The second one is the implied dispute resolution unless there is a different agreement between the covered person(s) and the insurer
The limitation of action for the insured or the beneficiary to claim for indemnity or insurance benefit against the insurer shall be two (2) years, which commences from the date the insured or the beneficiary is aware of or ought to be aware of the occurrence of the insured event.
7.23 Claim Procedures
You must comply with the following stipulated time limits and procedures before any benefits are payable under this Policy:
a) Written notice shall be given to us as soon as possible and in any event, within thirty (30) days after the occurrence of any event, which may give rise to a claim under this Policy.
b) A claim form obtainable from us upon request and all necessary supporting evidence of the occurrence, nature and extent of loss shall then be submitted to us within sixty (60) days after the occurrence of the event giving rise to a claim under this policy. All certificates, receipts, information
and evidence required by us shall be provided by you in the form prescribed by us and at no cost to
us
c) We shall have the right and the opportunity through our medical representatives to examine any covered person whenever and as often as may be reasonably required during our assessment of any claim. In addition, we shall have the right to require an autopsy in the case of death, where this is not forbidden by law or such religious beliefs that are recognized by the law. We will bear the expenses incurred in such examinations, unless we deny your claim, in which case we shall be entitled to recover all the expenses so incurred from you.
Please refer to the Membership Guidelines for our contact details for General Enquiries / Claims / Request for Emergency Medical Evacuation or Repatriation.
You may also refer to the Membership Guidelines for the full procedure and services available.
Section 8 – Benefits Table
SCHEDULE OF BENEFITS AND COVERAGE (Benefit limits are in USD) | |||
Lifetime Maximum : | Unlimited 2 | ||
Per Illness / Injury Maximum Limit | Unlimited 2 | ||
Level of Reimbursement | Reasonable and Customary ( R & C ) Charges | ||
Area of Cover | USA | ||
Maximum Outside Area of Cover Limit per covered person per policy year | USD 500 3 | ||
USA (In-Network) | USA (Out-of- Network) | Outside USA | |
Deductible (Per covered person per policy year) | USD 250 | USD 500 | USD 250 |
Eligible medical expenses payable at the plan co- insurance percentage specified, unless otherwise stated under the benefit | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
Out of Pocket Maximum by the covered person per policy year | USD 6,350 | Not Applicable | Not Applicable |
In-patient and daycare treatment benefits | |||
Hospital Room & Board – Semi- Private Room 6 | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
Hospital Charges 6 • Diagnostic procedures • Surgical procedures • Operating theatre charges • Nursing care, drugs and dressings • Surgical appliance and surgical implants • Surgeon and anaesthetist charges • Intensive care unit and high dependency unit charges • CT scan, MRI, x-rays and other such proven medical imaging techniques • Chemotherapy and/or radiotherapy • Kidney dialysis | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
Organ Transplant 6 | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
Mental Health 6 (treated as any other eligible medical condition) | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
Injury from Attempted Suicide/Self-inflicted Injury | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
Alcohol and Substance Abuse 6 | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 80% of the eligible expenses after applying the deductible |
AIDS, HIV, and Sexually Transmitted Diseases 6 | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 80% of the eligible expenses after applying the deductible |
Out-patient treatment benefits | |||
Co-Payment per visit by the covered person to a General Practitioner who is not from the University Student Centre or Student Health Centre 8 | USD 25 | USD 50 | USD 25 |
Co-Payment per visit by the covered person to a Specialist who is not from the University Student Centre or Student Health Centre 8 | USD 50 | USD 100 | USD 50 |
Out-patient Treatment 6 • Consultation 7 • Diagnostic procedures • CT Scan, PET Scan, MRI • Radiotherapy and/or Chemotherapy • Kidney dialysis • Out-patient Surgical Procedures | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
Out-patient Prescription Drugs 4 6 (co-payment do not apply to this benefit) | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
Emergency Out-patient Treatment– (Deductible waived if admitted as an in-patient) | 100%of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
Therapeutic Services 6 • Occupational Therapy • Physical Therapy • Speech Therapy | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
subject to USD 50 per visit and a maximum of 30 days per covered person per policy year | |||
Acupuncture and Homeopathy • Illness related treatments only | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
subject to USD 500 per covered person per policy year | |||
Maternity benefits | |||
Maternity Care for covered pregnancy 6 | |||
• Pre- and post-natal routine care 5, • Pre- and post-natal complications 5 and • Cost of delivery • Investigation and treatment to the cause of infertility * Dependent daughters are excluded from the coverage * No waiting period on coverage. * Conception must occur after the policy effective date | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 80% of the eligible expenses after applying the deductible |
Contraception 6 (deductible and co-insurance do not apply to this benefit) | 100% | No Benefit | No Benefit |
Abortion 6 | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 80% of the eligible expenses after applying the deductible |
subject to USD 500 per covered person per policy year | |||
New born benefits | |||
Premature Birth, Congenital conditions, Anomalies of the New born. | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 80% of the eligible expenses after applying the deductible |
Routine New born Care | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
Other benefits | |||
Dental Treatment due to accident | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
subject to USD 300 per tooth and a maximum of USD 600 per covered person per policy year | |||
Paediatric Dental and Vision (for dependent child < 19 years old) (deductible do not apply to this benefit) | 100% of the eligible expenses | 70% of the eligible expenses | No benefit |
Out-patient routine dental check-up subject to 2 visits per policy year Vision examination subject to 1 per policy year Eye glasses and contact lens subject to US$ 150 per policy year | |||
Health Screening/Preventive Care (deductible and co-insurance do not apply to this benefit) | 100% | No Benefit | No Benefit |
Extended Care / Inpatient Clinics /in-patient Rehabilitation 6 | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 100% of the eligible expenses after applying the deductible |
subject to maximum of 30 days per covered person per policy year | |||
Hospice and palliative care 6 | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 80% of the eligible expenses after applying the deductible |
subject to lifetime maximum of 30 days | |||
Home Health Nurse / Skilled Nursing / In-Home Nurse / Private Duty Nurse 6 | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 80% of the eligible expenses after applying the deductible |
subject to a maximum of 100 days per covered person per policy year | |||
Intercollegiate, interscholastic, intramural, club sports 6 | 80% of the eligible expenses after applying the deductible Up to USD 1500 per covered person per policy year | 60% of the eligible expenses after applying the deductible Up to USD 1500 per covered person per policy year | 80% of the eligible expenses after applying the deductible Up to USD 500 per covered person per policy year |
Durable Medical Equipment 6 | 80% of the eligible expenses after applying the deductible | 60% of the eligible expenses after applying the deductible | 80% of the eligible expenses after applying the deductible |
Local Road Ambulance | 100% of the eligible expenses after applying the deductible | ||
Pre-Existing Condition | No waiting period | ||
Non Pre-certification Penalty | 50% of eligible medical expenses | ||
Emergency Medical Evacuation and Repatriation 10 | Unlimited | ||
Repatriation of Remains 10 | Unlimited | ||
Emergency Reunion 10 (deductible and co-insurance do not apply to this benefit) | USD 5,000 per covered person per policy year and a lifetime maximum of 15 days. | ||
Accidental Death and Dismemberment | Principle Sum - Lifetime Maximum USD 25,000 (Insured person) USD 10,000 (Spouse) USD 5,000 (Child) | ||
Note:
1. This summary of benefits is provided as a brief outline of the benefits offered under the StudentCare Exclusive plan. Please refer to the policy contract for further clarifications, and the terms and conditions of the benefits.
2. The lifetime maximum is unlimited unless the limit is stated under the benefits.
3. Coverage outside USA is subjected to a maximum of USD 500 (cumulative of all benefits) after applying the deductible and co-insurance.
4. Any prescribed drug or other medication required for more than thirty (30) days should be pre- approved by us.
5. We pay post-natal costs routine care and post-natal complications up to ninety (90) days following the delivery of the baby.
6. Pre-certification is compulsory otherwise, the covered person will be required to bear fifty percent (50%) of the eligible expenses after deductible, co-insurance and co-payment (if applicable), not exceeding any limit stated.
7. Pre-certification is not applicable for out-patient consultation.
8. Co-payment is not applicable for out-patient treatment at the University Student Centre or Student Health Centre
9. Out of Pocket Maximum refers to the most each covered person pays during the policy year including deductible, co-payment and co-insurance. Once this amount is reached, the benefit plan pays 100% of the allowed amount for covered services.
The following expenses shall not be accounted in the accumulation for the Out of Pocket Maximum:
a) Expenses incurred for non-covered services and supplies or in excess of the maximum allowed amount
b) Non Pre-certification Penalty
10. These services are to be arranged by our chosen international assistance company. No benefits will be payable if our chosen international assistance company was not informed of the activation of such services or these services were not arranged by us.