Contract
亞太財產
保險有限公司
易全保團體醫療保險
（2024年4月版)條款
02 | 易全保團體醫療保險（2024年4月版）條款 | 目錄
目錄
一. 條款
1 總則 03
2 保險責任 04
3 責任免除 12
4 保險金額和保險費 16
5 保險期間 16
6 保險人義務 17
7 投保人、被保險人和受益人義務 18
8 保險賠償和支付 19
9 爭端解决與適用法律 20
10 其他條款 21
11 通用條款 23
12 定義 24
二. 保障一覽表 29
易全保團體醫療保險（2024年4月版）條款 | 總則 | 03
一. 條款
1. 總則
亞太財產保險有限公司
團體易全保醫療保險(2024年4月版)條款
(註冊編號: C00003832512024032959041)
第一條
本保險合同由保險條款﹑團體投保單﹑保險單或保險憑證﹑保障一覽表和批註構成。凡涉及本保險合同的任何其他協議, 均應採用書面形式, 並經保險人同意。
第二條
投保人是指為被保險人投保本保險的團體。在本保險合同的生效日期及隨後的所有續保日期時，符合被保險人資格的在職員工不得少於3人。
第三條
1. 直接被保險人：投保人所有在職全職員工。
2. 連帶被保險人：連帶被保險人的範圍由投保人在投保時決定, 其中可以包括以下直接被保險人的家庭成員：
a. 直接被保險人的合法配偶。
b. 直接被保險人的子女(年齡在18周歲以下的或在28周歲以下的且正在保險人認可的教育機構中註冊的全日制學生)。該類連帶被保險人的承保需獲取保險人的同意, 並應由投保人確定其在本保單下享有的保障範圍。
c. 其他被保險人書面同意的人。
直接被保險人可申請將(直接被保險人或其配偶所生)新生嬰兒加入本保單，自嬰兒出生之日起生效。如果直接被保險人在嬰兒出生後30 天內將其加入保單, 則無需填寫嬰兒的詳細病史。xxxxxxxxxxxx.xxx-xxxxxx.xxx，在直接被保險人在線組合區進行申請。
但如果出現以下情況， 保險人將要求提供嬰兒的詳細病史：
– 嬰兒在直接被保險人的保單生效日期或其配偶的保單生效日期(以最晚日期為準)起計的10 個月內出生;
– 嬰兒是被收養；
– 嬰兒是通過輔助受孕方法或任何類型生育治療(包括但不限於生育藥物治療)出生的。
在此情況下，保險人保留其對所提供保障範圍應用特別限制條款的權利，且保險人應在合理的時間內將這些條款通知直接被保險人。這可能會限制直接被保險人的嬰兒的現有醫療狀況的醫療保障。這意味著直接被保險人的嬰兒的保障範圍不包括參保前因某些醫療狀況所接受的治療，例如在新生嬰兒特別護理病房進行的治療，此類相關費用應由直接被保險人承擔。
保險人有權拒絕將直接被保險人的某一或某幾位家庭成員加入本保險合同，並應在合理的時間告知投保人。
3. 任何連帶被保險人的醫療保障均應與直接被保險人相同，但投保人和保險人對連帶被保險人的醫療保障的保障範圍作出特別限制的除外。
4. 本保險合同中的直接被保險人和連帶被保險人統稱為被保險人。
5. 擁有美國國籍，並且每年在美國境內居住超過90日(包括90日)的自然人，不能作為本保險合同的
被保險人。如被保險人在任一投保人與保險人雙方一致同意的排除在保障區域之外的國家/地區居住，則保險人不能 為其承保。在承保前，保險人應將保障區域之外的國家/地區列表告知投保人。
第四條
除另有約定外，本保險合同的受益人應指被保險人本人。
第五條 — 保險責任
在本保險合同的保險期間內，如果發生了本保險合同列明的醫療事項，保險人應按以下情況向被保險人支付 保險金。特定項目的保險金金額不得超過相應的保障限額，且支付的總保險金金額不得超過本保險合同中規定的年度最高保障限額。實際發生的所有費用必須為醫療上必需的費用，並應在合理及慣常收費範圍內。
本保險責任第1至第24款為必須選擇的保障項目，第25至38款為可供選擇的保障項目。
1. 醫院收費、醫生和專科醫生費用
a. 醫院對住院或日間留院治療的患者收取的費用包括：床位費（一般病房/雙人病房或私人病房）；
診斷檢測費用；手術室費用（含外科醫生與麻醉師收費）；合格護士護理的費用；由醫生或專科醫生開具的藥物和敷料的費用；手術期間醫生使用的手術器械費用；住院或日間留院期間手術前後的
咨詢費；重症監護費用。上述保障需要預先獲得保險人書面同意，而且其最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
b. 輔助器材費用：屬於保障範圍內並因醫療所需，在住院或日間留院接受治療的6個月內，用於購買及租賃拐杖、支撐架、輔助行走器和自推式非ℝ子輪椅的費用。上述費用的最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
2. 診斷程序
保險人應賠付由醫療必需而引致的實際醫療費用，包括:磁共振成像掃描(MRI)、正ℝ子放射斷層掃描(PET)和計算機斷層成像掃描(CT)的費用。正ℝ子放射斷層掃描(PET)、磁共振成像掃描(MRI)和計算機斷層成像
掃描(CT)需要預先獲得保險人書面同意。上述的最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
3. 腎衰竭和腎透析
保險人應賠付被保險人住院、日間留院或在門診部接受腎衰竭(包括腎透析)治療時實際產生的醫療費用。上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
4. 器官移植
保險人應賠付以下項目實際產生的醫療費用：
被保險人是器官受贈人時，有關腎臟、胰臟、肝臟、心臟、肺、骨髓、角膜的人體器官移植治療時產生的醫療費用。當器官移植是由先天性疾病導致時，相關醫療費用應當依照本保險合同第五條項下第7款(先天性疾病)進行賠付，此時本保險合同第五條項下第4款(器官移植)對於相關費用一概不予賠付。
保險人僅賠付滿足以下條件的器官移植：在國際認可的醫院並由獲得認證的外科醫生執行器官移植；並根據WHO指南獲取的器官。
器官捐獻者和尋找器官捐獻者的相關醫療費用一概不予賠付。
上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
5. 癌症治療
保險人應賠付因癌症而須住院、日間留院或門診治療時實際產生的醫療費用。
此保障包括從診斷之時起，產生的腫瘤科醫生的費用、手術費用，放射療法和化學療法的單項或綜合費用。上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
6. 新生嬰兒保障
保險人應賠付被保險人的新生嬰兒因早產(即妊娠未滿37週分娩)或被保險人的新生嬰兒在出生30日內出現急性的病症而需住院接受治療時而發生的實際醫療費用。
此保障提供的前提是新生嬰兒在出生之日起30日內已經加入本保險合同並且投保人已支付保險費。如果保險人在嬰兒被加入保單之前需要詳細了解新生嬰兒的病史，則保險人保留其對所提供保障範圍應用特別限制條款的權利。
請參閱第3條條款 － 新增新生嬰兒保單條款有關詳細信息。
此保障經投保人和保險人雙方同意可適用於多胎分娩的情況。上述的最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
7. 先天性疾病
保險人應賠付被保險人因先天性疾病進行住院治療時實際產生的醫療費用。若新生嬰兒出生30日內因先天性疾病接受治療，將根據本保險合同第五條第6款 – 新生嬰兒保障規定提供此類病症的保障，而本條款先天性疾病保障則不適用。最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
8. 家長住宿費用
保險人應賠付18周歲以下的被保險人因接受符合保障範圍內的住院治療時，其一位家長在醫院陪伴過夜而實際產生的住宿費用。上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
9. 新生嬰兒陪伴母親的醫院住宿費用
保險人應賠付新生嬰兒（出生16週及以下）在陪伴母親（母親為被保險人）接受住院治療符合保障範圍內的疾病時，醫院為新生嬰兒提供住宿而產生的實際費用。上述的最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
10. 整形外科手術
保險人應賠付被保險人接受整形外科手術的實際醫療費用，此整形外科手術是為了恢復正常人體的功能
或外貌，同時此整形外科手術是因被保險人在保險單生效日或批單簽發日（二者以後發生日為準）之後遭遇符合本保險合同保障範圍的意外事故或因接受符合本保險合同保障範圍內的疾病而接受了外科手術後
產生的。上述的最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
11. 日間留院和門診手術
保險人應賠付被保險人在外科診所、醫院、日間護理中心或門診部進行的外科手術時實際產生的治療費用。上述保障範圍內的最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
12. 緊急住院牙科治療
被保險人因遭遇意外事故而必須住院一晚以上，其天然健全的牙齒因需進行緊急牙科修復治療，保險人應按實際發生的醫療費用賠付給被保險人。
該牙科治療必須在意外事故發生後的10日內進行。此保障包括因意外的外部撞擊造成的口腔傷害而須接受治療時產生的所有費用，但同時應滿足以下條件：
a. 如果上述治療涉及更換齒冠、牙橋貼片、牙齒貼面或假牙，則保險人賠付合理慣常的費用，或賠付類似的或質量相當的更換費用；
b. 如果臨床角度上需要植牙，那麼保險人賠付採用橋托產生的費用；
c. 修復或重建在遭遇意外事故後損壞的假牙，但要求被保險人在遭遇意外事故時佩戴此類假牙。
上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
13. 康復治療
專科醫生針對被保險人所患疾病進行治療時，推薦被保險人接受保險人認可的醫院康復中心接受住院康復治療，保險人應賠付此種情況下實際產生的康復治療費用。但必須：被保險人連續三日住院；專科醫生 書面確認被保險人此時有必要接受康復治療。應在出院後14日內辦妥康復中心住院手續。上述治療應接受專科醫生的直接監管，並賠付如下費用：
a. 專項治療病房的使用費；
b. 物理治療費用；
c. 語障治療費用；
d. 職業病治療費用。
最高保障限額以及每一病症的最高保障天數，應經投保人與保險人雙方同意，並在保險合同中列明。
14. 家居護理
保險人應賠付以下實際產生的醫療費用：
由醫生或專科醫生推薦，在被保險人接受住院或日間留院治療後，由合格護士在被保險人家中提供護理的費用。此保障必須預先獲得保險人書面同意。
最高保障限額及最高護理天數應經投保人與保險人雙方同意，並在保險合同中列明。
15. 緊急救護運送費用
保險人應賠付陸上緊急救護交通運輸工具接送或在醫院之間轉送途中，或經醫生或專科醫生認為醫療 必需的交通運輸工具實際產生的費用。上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
16. 轉運和送返
保險人應賠付以下項目實際產生的費用：
a. 轉運
保險人安排患有符合保障範圍內的危重被保險人運送到最近的醫療機構進行住院或日間留院治療。賠付如下合理費用：
i. 在被保險人須接受緊急治療而事故發生地無法提供醫療上必需的救護接送與護理的情況下，運送被保險人時產生的交通費用。其中包括一名隨行照料人員陪護行程中的經濟艙機票；
ii. 被保險人在接受日間留院治療期間，往返醫院赴診時的當地合理交通費用；
iii. 被保險人入院後隨行照料人員由於看望被保險人往返醫院時產生的合理交通費用；
iv. 僅限住院前或出院後短期內，被保險人接受專科醫生護理時的合理非醫院住宿費用。
在保險人認可的滑雪場或類似的冬季運動場所範圍之外，進行任何海空營救或山地救援時產生的轉運費用，一概不予賠付。
保險人的醫學顧問將決定轉運時的最合適的交通方式。如違背保險人醫學顧問的意見，保險人不賠付交通費用。另外，如果被保險人前往的醫院不具備合適醫療設施用以治療被保險人之符合保障範圍的醫療情況，則相關的交通費用將不予賠付。
b. 送返
經由醫療上必需且由保險人安排的轉運之後，在被保險人完成治療後的一個月內，在治療地的被保險人與被保險人的一位隨行照料人員將可獲安排經濟艙機票返回被保險人的國籍國或居住國。
需要已經完成最初的醫療上必需的轉運, 才可賠付此交通費用。免賠額適用於此計劃保障。
上述保障需要預先獲得保險人書面同意。上述保障的最高保障限額以及每次轉運過程中的最高保障限額，應經投保人與保險人雙方同意，並在保險合同中列明。
17. 遺體運送
保險人應賠付被保險人因保障範圍內的醫療狀況導致死亡時產生的以下合理和慣常的費用：
a. 將被保險人遺體或骨灰運往其國籍國或居住國的費用，或
b. 在被保險人死亡所在地，根據合理的慣例進行土葬或火葬時產生的費用。
上述保障需要預先獲得保險人書面同意。最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
18. 保障區域以外的緊急非選擇性治療
在不超過30日（含30日）的計劃行程中，被保險人在保障區域以外若遇到意外事故或因某種突發性醫療狀況而形成對被保險人的健康構成威脅的突發危重疾病，而且其在上述緊急事件之後的24小時內接受醫生或
專科醫生提供的治療，則保險人應賠付該期間實際產生的醫療費用。
上述保障範圍內的最高保障限額，應經投保人與保險人雙方同意，並在保險合同中列明。
19. 住院現金津貼
保險人應賠付被保險人在醫院接受住院治療期間每一晚的現金住院津貼，但應滿足以下條件：
a. 被保險人在零時前於居住國家的公立醫院接受選擇性住院治療；或
b. 該計劃是二級醫療保險計劃。但是，如果被保險人的計劃免賠額是人民幣63,000或人民幣94,500，被保險人不可享用此保障。
該保障僅限於每個保險期間內累計最長不超過30晚（含30晚）。責任免除6.9條款並不適用於此保障。
上述保障範圍內的最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
20. 門診醫生費用
保險人應賠付以下實際發生的醫療費用：
a. 含括諮詢費在內的醫生收費，專科醫生費用，診斷檢查費用；
b. 遠程醫療諮詢(醫生以ℝ子方式進行遠程醫療諮詢)；
如果被保險人在時康國際公佈的易全保綜合醫療網絡內列明的醫療服務提供方接受治療，符合保障範圍內的治療費用將全額賠付。
如果被保險人不是在時康國際公佈的易全保綜合醫療網絡內列明的醫療服務提供方接受治療，則只會賠付符合保障範圍內合理和慣常的醫療費用。
c. 處方藥和敷料的費用；
d. 維生素和礦物質。
由醫生開具的維生素和礦物質。按照門診福利保障為維生素缺乏症確診者賠付由醫生開具的維生素。
任何手術前和出院後的門診費用將根據此保障進行賠付。
被保險人的保障範圍不包括被保險人因調理慢性疾病而承擔的費用。如果被保險人根據易全保翡翠計劃，易全保水晶計劃保險單選項投保則保險人將在本保險合同第五條項下第20款門診醫生費用承擔調理慢性疾病的治療費用。
請注意：如果索賠收據未顯示所提供醫療服務的明細，我們將僅支付不超過處方藥和敷料限額的符合條件的索賠。
年度門診限額：適用於保險合同第20款和21款，受年度最高保險計劃限額限制。上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
21. 門診物理治療和替代療法
保險人應賠付以下項目實際產生的醫療費用：
a. 由獲得執業許可的物理治療師提供的物理治療費用。
b. 被保險人接受理療師的輔助藥物和治療，此類賠償可包括整骨療法、手足病治療和足病治療、整脊療法、順勢療法、飲食療法和針灸療法的費用。
c. 中醫執業醫師或阿育吠陀醫學執業醫師對被保險人進行門診治療時實際產生的醫療費用。
保險期內您可選擇此保障a.或b，合計首5次治療不需轉介(飲食療法除外)，其他後續治療需醫生或專科醫生轉介。
年度門診限額：適用於保險合同第20款和21款，受年度最高保險計劃限額限制。
最高保障限額以及每個保險期間內的最高治療次數應經投保人與保險人雙方同意，並在保險合同中列明。
22. 更年期激素替代治療
保險人應賠付被保險人因需要進行激素替代治療以緩解更年期早發症狀之門診費用，但更年期發病和治療須始於40歲以下。上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
23. 門診精神疾病治療
由法定資質的心理學家和/或法定資質的精神病醫生的直接管理下，被保險人接受的門診治療。此項保障包括10次治療，賠付費用以本保障限額為準。
前5次就診無需醫生轉介，之後的就診則需要有醫生或專科醫生的轉介函和治療計劃。
最高保障限額以及每個保險期間內的最高治療次數應經投保人與保險人雙方同意，並在保險合同中列明。
24. 牙科
保險人應賠付以下項目實際產生的醫療費用：
牙科治療：牙科執業醫生在牙科手術期間/牙科診所進行牙科治療的費用。牙科治療包括：
– 牙齒檢查(若有必要其中包括照牙科X光)；
– 預防性洗牙，拋光和窩溝封閉(每年一次)；
– 補牙和拔牙(非手術和手術性)；
– 根管治療；
– 新裝或修復牙冠，假牙，嵌體和牙橋；
– 進行牙根尖切除術。
不包括種植牙和牙齒矯正治療保障。
其他牙科治療一概不屬於此類保障。
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。
此保障有20%的自付比例。
免賠額或門診每次就診免賠額並不適用於此保障。
上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
25. 中國大陸選擇
保險人應賠付被保險人在中國大陸因住院、日間留院及接受門診治療時實際產生的符合保障範圍的醫療費用。標準的保險單保障限額適用於本條。
中國大陸以外的緊急非選擇性治療：
在最長期限為30日的計劃行程中，被保險人若在中國大陸以外的地區遇到意外事故或因某種突發性醫療狀況而引致對其健康構成即時威脅的嚴重疾病，在上述緊急事件之後的24小時內接受的醫生或專科醫生提供的治療。
因意外事故，需接受住院和日間留院治療，保險人應全額賠付。
因疾病需接受住院和日間留院治療，以投保人和保險人雙方同意的最高保障限額為限。最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
26. 病房限制(住宿最高限額800人民幣)
如本保險合同第五條項下第1款(a)項所述，被保險人在中國大陸住院時，每日最高限額800人民幣，從而在中國大陸醫院接受保障範圍內的住院或日間留院治療及任何醫生的治療。醫院的定義及範圍由保險人
事先約定。
最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
27. 昂貴醫院限制
保險人將事先指定某些提供住院、日間留院或門診治療服務的醫療機構為昂貴醫院。被保險人在中國大陸任何一家昂貴醫院接受保障範圍內的住院、日間留院或門診治療及任何醫學專家的治療時，保險人將不會賠付實際產生的有關醫療費用。
28. 私人醫院住院自付比例
對屬於保障範圍內在私人醫院的住院或日間留院治療時實際產生的醫療費用，被保險人需承擔20%自付比例。
上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
29. 年度最高保障限額1,000,000人民幣
在本保險合同的保險期間內，如果發生了本保險合同涵蓋的醫療事項，保險人應支付保險金額不得超過相應的保障限額，且支付的總保險金金額不得超過本保險合同中規定的年度最高保障限額1,000,000人民幣。
30. 門診費用的自付比例
保險人應賠付被保險人符合保障範圍內的門診治療實際產生的醫療費用，但門診治療有20%的自付比例。
自付額並不適用於以下項目：
癌症治療、器官移植、腎衰竭和腎透析。
但此項不適用於6,300人民幣免賠額或更高免賠額之計劃。
最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
如果被保險人的保險單中含有生育保障﹑牙科保障或體檢﹑疫苗保障，其相應的自付額將會在被保險人的保障一覽表中列明。
31. 門診每次就診免賠額
被保險人接受屬於保障範圍的門診治療時，門診每次就診設有150人民幣免賠額。
門診每次就診免賠額適用於本保險合同第五條第20款(門診醫生費用)和21款(門診物理治療和替代療法)。但此項不適用於6,300人民幣免賠額或更高免賠額之計劃。
上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
32. 取消藥物和敷料限額
通過選擇此選項，保障20 c)下的處方藥和敷料將全額賠償，但受年度最高門診限額限制。適用於3名員工或以上的統一投保的團體保險單。
上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
33. 體檢和疫苗 – 選項1
保險人應賠付以下項目實際產生的有關醫療費用：
a. 體檢保障：保險人應賠付例行健康檢查，包括癌症篩查、乳腺癌1號和2號基因檢查(如直系家屬有
病史)、骨密度檢查(50周歲以上女性被保險人每5年可做1次)、心♛管系統檢查，神經系統檢查、生命體徵檢查(例如，♛壓、體重指數、尿分析和膽固醇)、兒童體檢(至5周歲)的費用和/或
b. 疫苗保障：醫療必需的免疫疫苗和加強藥物注射，以及醫療必需的任何旅行疫苗和瘧疾預防注射，保險人將賠付相關藥物費用和咨詢費用。
適用於3名員工以上的統一投保的團體保險單。
責任免除6.9條款並不適用於此保障。上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
34. 體檢和疫苗 – 選項2
保險人應賠付以下項目實際產生的有關醫療費用：
a. 體檢保障：保險人應賠付例行健康檢查，包括癌症篩查、乳腺癌1號和2號基因檢查(如直系家屬有
病史)、骨密度檢查(50周歲以上女性被保險人每5年可做1次)、心♛管系統檢查，神經系統檢查、生命體徵檢查(例如，♛壓、體重指數、尿分析和膽固醇)、兒童體檢(至5周歲)的費用和/或
b. 疫苗保障：醫療必需的免疫疫苗和加強藥物注射，以及醫療必需的任何旅行疫苗和瘧疾預防注射，保險人將賠付相關藥物費用和咨詢費用。
適用於3名員工以上的統一投保的團體保險單。
責任免除6.9條款並不適用於此保障。上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
35. 生育保障 – 選項1
保險人應賠付以下項目：
a. 被保險人懷孕或分娩期間實際產生的醫療必需費用；包括分娩費用、產前與產後六週內檢查、掃描、自然分娩或自願/緊急剖腹產的費用。本保障亦包含出生24小時內兒科醫生就新生嬰兒首次檢查/體檢的收費，以及幼兒 1週歲生日前由醫生或專科醫生建議的兒科健康檢查費用，包括體格檢查，身高體重頭圍胸圍等測量，視力
聽力等感知覺篩查，智能心理評估，生長發育檢查，遺傳病及代謝疾病篩查，疫苗注射，尿檢，結核試驗，
♛球容積比，♛紅蛋白及其他♛液檢查，包括鐮狀細胞貧♛的篩查。 請注意此新生嬰兒檢查的費用保障，僅限於保險人已賠付本團體計劃下被保險人的分娩費用，且新生嬰兒已加入此團體計劃並成為被保險人時，保險人才會賠付上述新生嬰兒檢查的費用。
b. 對於產前期間因保障範圍內的醫療狀況所產生的實際住院治療費用或分娩期間因保障範圍內的醫療狀況所產生的實際住院治療費用，保險人僅將治療以下醫療狀況視為此福利保障b)中符合保障範圍內的醫療狀況。
– 子宮外孕(胚胎在子宮以外的部位著床發育)；
– 葡萄胎(異常細胞在子宮內生長)；
– 胎盤滯留（胚胎滯留在子宮內)；
– 前置胎盤；
– 子癇(懷孕期間發生在先兆子癇之後的昏迷或抽搐)；
– 糖尿病(如果被保險人因自身與糖尿病有關的過往病史而有相應的責任免除，則被保險人不會因懷孕期間進行的任何糖尿病治療而獲得賠償)；
– 產後出♛(分娩後多個小時及多日大出♛)；
– 需要實時接受外科治療的流產。
本保障b)不包括自願/緊急剖腹產或“產程進展不良”的費用，除非是上述保障b)所列之符合保障範圍內的醫療狀況之一。
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。在第180日後至保單生效一年期間
產生的費用，此保障有95%的自付比例。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。
因這是個人選擇，保險人對於育兒或其他相關課程一概不予賠付。適用於10名或以上的團體保單。
責任免除6.27條款並不適用於此保障。免賠額適用於此保障。
每個保險期間內的最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
36. 生育保障 – 選項2
保險人應賠付以下項目：
a. 被保險人懷孕或分娩期間實際產生的醫療必需費用；包括分娩費用、產前與產後六週內檢查、掃描、自然分娩或自願/緊急剖腹產的費用。本保障亦包含出生24小時內兒科醫生就新生嬰兒首次檢查/體檢的收費，以及幼兒 1週歲生日前由醫生或專科醫生建議的兒科健康檢查費用，包括體格檢查，身高體重頭圍胸圍等測量，視力
聽力等感知覺篩查，智能心理評估，生長發育檢查，遺傳病及代謝疾病篩查，疫苗注射，尿檢，結核試驗，
♛球容積比，♛紅蛋白及其他♛液檢查，包括鐮狀細胞貧♛的篩查。請注意此新生嬰兒檢查的費用保障，僅限於保險人已賠付本團體計劃下被保險人的分娩費用，且新生嬰兒已加入此團體計劃並成為被保險人時，保險人才會賠付上述新生嬰兒檢查的費用。
b. 對於產前期間因保障範圍內的醫療狀況所產生的實際住院治療費用或分娩期間因保障範圍內的醫療狀況所產生的實際住院治療費用，保險人僅將治療以下醫療狀況視為此福利保障b)中符合保障範圍內的醫療狀況。
– 子宮外孕(胚胎在子宮以外的部位著床發育)；
– 葡萄胎(異常細胞在子宮內生長)；
– 胎盤滯留（胚胎滯留在子宮內)；
– 前置胎盤；
– 子癇(懷孕期間發生在先兆子癇之後的昏迷或抽搐)；
– 糖尿病(如果被保險人因自身與糖尿病有關的過往病史而有相應的責任免除，則被保險人不會因懷孕期間進行的任何糖尿病治療而獲得賠償)；
– 產後出♛(分娩後多個小時及多日大出♛)；
– 需要實時接受外科治療的流產。
本保障b)不包括自願/緊急剖腹產或“產程進展不良”的費用，除非是上述保障b)所列之符合保障範圍內的醫療狀況之一。
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。在第180日後至保單生效一年期間
產生的費用，此保障有95%的自付比例。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。
因這是個人選擇，保險人對於育兒或其他相關課程一概不予賠付。適用於10名或以上的團體保單。
責任免除6.27條款並不適用於此保障。免賠額適用於此保障。
每個保險期間內的最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
37. 已聲明的既往病症的限額
只適用於5-19名員工的統一投保的團體保險單。
此核保選項為已向保險人聲明並被保險人接受的既往病症提供有限的承保。
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。
上述最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。
38. 既往病史不咎
適用於10名員工以上的統一投保的團體保險單。
第六條 — 責任免除
即使根據醫生或牙醫開具的處方、建議或同意，被保險人因下列情形之一接受治療或發生相關費用的， 均不在保障範圍之列。除在保險單和保險憑證中詳細列明的所有除外責任外，以下團體保險單的除外責任亦同樣適用。
6.1 恐怖主義行為、戰爭與違法行為
除非被保險人是無端受害的旁觀者，否則被保險人由於戰爭、外國敵對行為（無論是否宣戰）、內戰、叛亂、革命、暴動、軍事政變或篡奪政權、兵變、騷亂、罷工、戒嚴、試圖推翻政府或其他任何恐怖活動而直接或間接產生的治療費用不在保障範圍之列。由於被保險人參與任何違法行為而產生的費用均不在保障範圍之列。
6.2 行政與運輸費用
由於被保險人要求醫生或牙科醫生填寫理賠申請表或出具醫療報告而產生的任何費用均不在保障範圍 之列。被保險人在出具向警方報案證明時產生的任何費用均不在保障範圍之列。被保險人因運輸藥物而產生的任何貨運費用（包括關稅）均不在保障範圍之列。
6.3 酗酒與藥物濫用
被保險人因依賴或濫用酒精、毒品或其他成癮物質而產生的治療費用，以及由於依賴或濫用酒精、毒品或其他成癮物質而直接或間接導致的疾病或損傷均不在保障範圍之列。
6.4 化學品暴露
由於任何核燃料燃燒後的核廢物、或有放射性的、有毒，有爆炸性、或任何爆炸性核裝置或其核成分的 其他危險性質引起的電離輻射或放射性污染而直接或間接產生的或使被保險人承擔的治療費用均不在保障範圍之列。
6.5 整容/美容治療
被保險人由於進行美容或整形治療而產生的治療費用(無論是否出於心理因素目的)或與之前美容或整形手術相關的任何用於改善外觀的治療費用(包括但不限於痤瘡治療、牙齒美白、雀斑及脫髮治療)均不在保障範圍之列，即使該治療為醫療處方所建議。保險人僅賠付被保險人在參保期間內遭遇意外事故或因接受符合本保險合同保障範圍內的疾病而接受了外科手術，其後為了恢復正常人體功能或外貌而接受的整形外科手術（僅限於初次手術）。
6.6 污染
被保險人由於化學或生物污染直接或間接引起(而無論如何造成)、或任何核材料引起的輻射污染而產生的治療費用或索賠，或是因石棉沉滯症治療(包括由於戰爭或恐怖行為和以任何方式產生或導致的費用）而產生的任何病症的治療費用或索賠，均不在保障範圍之列。
6.7 慢性病
被保險人的保障範圍不包括被保險人因調理慢性疾病而承擔的費用。如果被保險人根據易全保翡翠計劃，易全保水晶計劃保險單選項投保則保險人將在本保險合同第五條項下第20款(門診醫生費用)承擔治療
費用。
6.8 昏迷或植物人狀態
保險人不承擔被保險人在昏迷或植物人狀態超過12個月的任何治療費用。然而，保險人將承擔在昏迷或植物人狀態的前12個月內符合本保險合同保障範圍內的疾病產生的的積極治療費用。
6.9 免賠額、門診每次就診免賠額或自付比例
被保險人的免賠額、門診每次就診免賠額或自付比例的金額(需在保險合同中列明)不在保障範圍之列。保險人對所有醫療機構提供的旨在向保險人索取更高賠償金額以支付免賠額、門診每次就診免賠額或自付比例的安排均視為欺詐行為，並將採取法律行動。
6.10 牙科護理
被保險人因進行口腔護理而產生的任何費用均不在保障範圍之列，除非這些保障包含在被保險人的保險憑證中。但是，保險人將承擔由於意外事故而產生的緊急住院牙科治療費用，詳情請參閱保障一覽表。在下列情形下，保險人不應承擔因進行牙科醫生咨詢或相關治療而產生的電話費或交通費、事故發生時假牙損傷的治療費(除非因意外造成)或意外牙齒損傷而產生的必要治療費用：
﹣在進食或飲用過程中造成的損傷，即使其中包含異物；
﹣損傷形成是由於口腔或牙齒正常的磨損和老化；
﹣從事拳擊或橄欖球運動（學生橄欖球除外）時造成的損傷，受傷時正確佩戴了適當的口部保護設備的除外；
﹣因非外部撞擊造成的口腔損傷；
﹣刷牙或其他口部清潔過程引起的傷害；
﹣損傷導致的傷害，此傷害的影響在發生損傷後的10日內並不明顯；
﹣損傷發生18個月後產生的治療費用，即便此治療是醫學上必須進行的操作。
6.11 發育異常
被保險人因存在發育、行為或學習等方面問題（例如注意缺陷多動障礙、言語障礙或誦讀障礙，以及身體發育問題）而接受治療所產生的費用不在保障範圍之列。
6.12 食物補充品和洗化產品
被保險人因購買以下產品而產生的費用不在保障範圍之列：營養或膳食方面的相關咨詢及食物補充品，包括但不限於，特殊嬰兒食品，洗化產品（包括但不限於保濕霜、潔膚用品、乳液、肥皂、洗髮水、
防曬霜、漱口水、抗菌含片，無論其是否為醫生推薦或處方或有公認的療效）等。
6.13 進食失調
被保險人因接受與進食失調（包括但不限於神經性厭食症和貪食症）相關的治療而產生的費用不在保障範圍之列。
6.14 實驗性治療和藥物
被保險人因接受尚未被證明有效或處於實驗階段的治療或藥物而產生的費用不在保障範圍之列。此處的 藥物是指必須獲得相關藥品管理局或藥品及醫療保健用品管理部門的使用許可，並在許可的條款範圍內 使用的藥物。此處所指的被證明有效的治療，係指治療程序和方法已經過相應的臨床試驗和評估，已得
到充分證明並發表在醫學期刊上，和/或獲得相關國家衛生醫療質量標準部門有關適用於特定目的並已被
證明為安全有效治療方法。
6.15 視力檢查或視力矯正、聽力檢查、聽力或視覺輔助
被保險人進行常規視力或聽力檢查的費用以及眼鏡、隱形眼鏡、助聽器或人工耳蝸移植手術的費用均不在保障範圍之列。為糾正視力而進行的眼部手術費用不在保障範圍之列，但是為治療符合上文保險責任條款中約定可以獲得賠償的醫療狀況而進行的眼部手術費用在保障範圍之列。
6.16 外部器械和/或假體
任何提供、維護或調試外用假體、器械或其它耐用醫療設備所產生的費用，均不在保障範圍之列。除非此類費用明列於醫院收費、醫生和專科醫生保險責任之內。
6.17 不遵醫囑
被保險人在下列情形中產生的治療費用不在保障範圍之列：因被保險人不合理的疏忽而無法尋求或遵從醫生囑咐和/或處方治療，或被保險人不合理地推遲尋求或遵從此類醫生囑咐和/或處方治療。被保險人因忽視此類囑咐而產生的並發症治療費用不在保障範圍之列。
6.18 胎兒手術
被保險人胎兒尚在母親子宮中時所做手術的費用不在保障範圍之列，除非該筆費用作為生育保障的一部分詳細列在被保險人的保險合同中。
6.19 基因檢測
當基因檢測旨在確認被保險人擁有的基因是否可能發展成某種醫療狀況，或者在毫無症狀的情況下是否已得了病，或者是否有遺傳風險產生的費用均不在保障範圍之列。
6.20 高風險運動及工作
被保險人因進行以下活動導致受傷而產生的相關費用不在保障範圍之列：定點跳傘、懸崖跳水、 賽車運動、乘坐未經註冊的飛機飛行、飛行學習、武術、自由攀岩、登山(不論是否使用繩索)、戴水肺潛水超過 30米、徒步行至海拔4,000米或以上、蹦極、溪降、懸掛滑翔、滑翔傘運動或乘坐機動滑翔飛翼、跳傘、洞穴探險，在滑雪道外滑雪或進行其他冬季運動。
6.21 人類免疫缺陷病毒、艾滋病或性傳染疾病
被保險人在下列情形下接受治療所發生的費用不在保障範圍之列，這些情形包括：因獲得性免疫缺陷綜合征(AIDS)、艾滋病相關綜合征(ARCS) 和所有由人體免疫缺陷病毒(HIV)導致的或與之相關(或兩者兼有)的疾病以及性傳播疾病而接受的治療。非醫療處方的艾滋病毒檢測或簽證申請篩查產生的費用均不在保障範圍列。
6.22 激素替代治療
被保險人因接受激素替代治療而產生的費用不在保障範圍之列。保險人應賠付被保險人為治療因醫療 干預所致的停經而接受的醫療上必需的激素替代治療和更年期激素替代治療（更年期發病和治療須始於 40歲以下），含醫生咨詢費，皮埋給藥、皮貼給藥或口服藥物的費用，該保障僅限於最長累計18個月的費用。
6.23 病態肥胖症
保險人因接受病態肥胖症治療或與之相關的治療而產生的費用不在保障範圍之列。被保險人因從身體任何部分移除脂肪或多餘的健康組織而產生的費用以及與之相關的費用均不在保障範圍之列。
6.24 在護理院、療養院、康體水療院和自然療法門診的治療
被保險人在護理院、療養院、康體水療院、自然療法門診或類似場所接受治療的費用均不在保障範圍 之列。相關療養費用或被保險人出於觀察目的而住院的費用不在保障範圍之列。如果延長護理的原因是
被保險人年老體衰，和/或醫院實際上已經成為被保險人的休息居住場所，則延長護理的費用不在保障範圍
之列。
6.25 姑息治療和臨終關懷
如果被保險人被醫生或專科醫生診斷為終末期疾病起，醫生或專科醫生以暫時緩解症狀為目的開立醫囑，保險人不賠付因姑息治療與臨終關懷而產生的住宿費用或任何其他治療費用。
6.26 投保前疾病
被保險人的保險計劃不承保投保前疾病及其相關醫療狀況疾病（不包括事先得到保險人書面同意承保的投保前疾病）。
投保前疾病的定義為任何疾病或損傷在保險單起始日期或者保險單加入日期前：
1. 曾接受過治療、測試或檢查，或曾被確切診斷，或曾接受過住院治療；或者
2. 曾出現過症狀，無論是否有過確切診斷
6.27 懷孕或分娩
被保險人因懷孕或分娩、醫療上必需的和/或緊急剖腹產、自願剖腹產、懷孕或分娩的醫療狀況，包括
產前、分娩或產後出現的醫療狀況而產生的費用不在承保範圍之列，除非生育保障a)列在被保險人的保險合同中。
這些費用僅包含在生育保障福利a)中，不包含在任何其他保障福利中或不能從任何其他保障福利中獲得賠付。
6.28 職業體育運動
由於被保險人參與任何形式的職業運動造成損傷或疾病而產生的任何費用不在保障範圍之列。保險人所指的職業運動指被保險人有償參與的運動。
6.29 精神或心理治療
被保險人因精神疾病或任何心理狀況相關的治療而產生的費用不在保障範圍之列，除非列明在被保險人保障計劃中。
6.30 不育症相關的治療
被保險人因接受有關不孕症和生育力、絕育(或其反面)或輔助受孕相關的檢查或治療而產生的費用不在保障範圍之列。被保險人承擔的與避孕相關的費用不在保障範圍之列。
6.31 例行檢驗、健康檢查、疫苗
如果相關保障未列在被保險人的保險合同中，則被保險人因接受常規醫療檢查而產生的費用(包括簽發健康證明、健康檢查或為排除被保險人罹患未表現出症狀的某一病症的可能性而進行的檢查等)和任何類型的疫苗費用不在保障範圍之列，除非保障列明在被保險人的保險合同中。
6.32 第二診療意見
未經保險人書面同意，被保險人因醫生或專科醫生就同一個醫療狀況產生的、被保險人保險合同中列明的醫療意見以外的任何補充性或後續醫療意見而產生的費用不在保障範圍之列。
6.33 自殘或試圖自殺
因被保險人自殘損傷、自殺或試圖自殺直接或間接產生的治療費用不在保障範圍之列。
6.34 性問題和變性
被保險人因接受與性功能障礙、變性手術等性問題相關的治療費用，以及由變性直接或間接引起的包括 心理治療或類似服務在內的手術或其他治療費用，均不在保障範圍之列。被保險人接受性傳播疾病治療的費用不在保障範圍之列。
6.35 睡眠失調
被保險人接受包括睡眠測試或矯正手術在內的針對打鼾、失眠、時差綜合征、疲勞、或睡眠呼吸暫停等的治療費用不在保障範圍之列。
6.36 旅行/住宿費用
被保險人為獲得醫療治療而進行的旅行期間所產生的交通或住宿費用不在保障範圍之列，除非此類費用是出於緊急醫療轉運目的，且已經保險人預先書面同意。因被保險人未經保險人預先書面同意及安排便進行的緊急醫療轉運或送返被保險人而產生的費用不在保障範圍之列。
6.37 違反醫生囑咐旅行的費用
如果被保險人不聽從主治醫生的囑咐而出行，則被保險人產生的醫療費用或其他費用不在保障範圍之列。
6.38 昂貴醫療機構的治療
被保險人在保險人昂貴醫療機構名單內的昂貴醫療機構接受任何治療而產生的費用不在保障範圍之列。
6.39 來自家庭成員的治療
來自家庭成員或用於自我療法的治療所產生的費用不在保障範圍之列。
6.40 超出合理及慣常收費范圍的治療費用
超出合理及慣常收費範圍的治療費用不在保障範圍之列。
16 | 易全保團體醫療保險（2024年4月版）條款 | 保險金額和保險費，保險期間
4. 保險金額和保險費
5. 保險期間
第七條 — 保險金額和保險費
1. 本保險合同中的保險金額即為保險人承擔的最高保障責任。在本保險合同的保險期間內，保險人為每一項的保障承擔的保障金額不應超過每一項保障的最高保障限額，且累計的保障金額不應超過保險保障總額。
保險保障總額和每一項保障的最高保障限額均經保險人和投保人一致同意，並在保險合同中列明。
2. 投保人應按照本保險合同的約定支付保險費。
3. 保險費根據投保人與保險人商定的保險金額計算，並在本保險合同中列明保險費率。
第八條 — 保險期間與續保
本保險合同的保險期間為一年。 具體起訖時間由投保人、保險人雙方約定，並載明於本保險合同中。
本保險合同為不保證續保合同，保險期間屆滿，投保人需要重新向保險人申請投保本產品，並經保險人同意，交納保險費，獲得新的保險合同。
第九條 — 等待期
等待期是指從保險單生效日或批單簽發日(二者以後發生日為準)，保險人不承擔某項特定保險責任的一段
時間，具體天數由保險人和投保人協商確定，但最長不超過180天。不管投保人續保與否，被保險人必須完成等待期才可賠付該保障。
第十條 — 免賠額
本保險合同有免賠額選項。免賠額適用於所有符合保障範圍的住院，日間留院和門診治療產生的費用（無論被保險人於醫療網內或醫療網外醫療機構治療）。如果投保人選擇其中一項的免賠額選項，投保人需要就門診費用的自付比例或門診每次就診免賠額的其中一項作出相關選擇。免賠額選項和其他相關的選項應經投保人與保險人雙方同意，並在保險合同中列明。
6. 保險人義務
第十一條 — 明確說明義務
簽訂保險合同時，由於採用的是保險人提供的格式條款，保險人向投保人提供的投保單應當附上格式條款，並向投保人說明及披露所有條款和條件。對於保險合同中免除保險人責任的條款，保險人應在團體投保單、保險單或其他保險憑證中給予明確提示，並對該條款的內容向投保人以口頭或書面形式作出明確說明。
如無提示或者明確說明的，該條款不產生效力。
第十二條 — 保險單簽發
保險人應在簽訂保險合同後為投保人及時簽發保險單或其他保險憑證。
第十三條 — 理賠資料的補充
如果保險人按照本保險合同的約定認為申請人提供的理賠申請或有關證明和資料不完整的，則應一次性及時通知投保人/被保險人提交所需的補充信息。
第十四條 — 保險金的核定與支付
保險人收到被保險人或受益人提交的理賠申請書及合同約定的證明和資料後，應及時核定。若案件情況比較複雜，除保險合同中另有約定外，保險人應在30日內作出核定。
保險人應將核定結果通知被保險人或受益人。對屬於保險責任範圍的，保險人應在與被保險人或受益人達成支付保險金的協議後的10日內履行支付保險金義務。如果雙方在支付保險金協議中對於支付保險金的期限 另有約定，則保險人應根據協議約定的期限支付保險金，以履行相應義務。經核定不屬於保險責任範圍的，保險人應在作出核定之日起3日內向被保險人或者受益人發出拒絕支付保險金通知書，並說明理由。
第十五條 — 保障期內的理賠處理
保險人自收到理賠申請和有關證明、資料之日起60日內，對其給付保險金的數額不能確定的，應當根據已有證明和資料可以確定的數額先予支付；保險人最終確定給付保險金的數額後，應當支付相應的差額。
18 | 易全保團體醫療保險（2024年4月版）條款 | 投保人、被保險人和受♛人義務
7. 投保人、被保險人和受♛人義務
第十六條 — 支付保險費
本保險合同保險費交納方式由投保人和保險人在投保時約定，並在保險單中載明。
如約定一次性交納保險費的，投保人應在保險合同成立時一次性交清保險費，投保人未按約定交納保險費的，本保險合同不生效。
約定以分期付款方式交納保險費的，需經投保人申請並經保險人同意，在保險合同中載明分期交納的周期，投保人應按約定交納首期保險費。如投保人未按保險合同約定交納首期保險費，保險合同不生效。
如投保人未按約定日期交納第二期或以後任何一期保險費的，投保人自保險人催告之日起超過三十日未支付當期保險費的，本保險合同效力中止；在本保險合同解除前發生保險事故的，保險人按照本保險合同約定給付 保險金，但需在保險金額中扣減保險期間內投保人所有未交期間的保險費，投保人已交納的保險費與保險人 扣減的保險費之和應等於本保險合同約定的保險費總額。
投保人應為本保險合同包括的所有符合資格的被保險人支付保險費。
第十七條 — 如實告知義務
簽訂保險合同後，保險人可能會調查投保人或被保險人的相關情況，投保人應如實告知。
如果投保人故意不履行或由於重大過失而未能履行其如實告知的義務，從而影響保險人對保險申請進行承保或增加保險費率的決定，則保險人有權解除合同。
前款規定的合同解除權，自保險人知道有解除事由之日起，超過30日不行使而消滅。
如果投保人故意不履行其如實告知的義務，則保險人不承擔合同解除前發生的保險事故的保險金賠付責任，並且不會退回保險費。
如果投保人因重大過失而未能履行其如實告知的義務，並成為導致保險事故發生的主要原因，則保險人不應承擔合同解除前發生的保險事故的保險金賠付責任，但應退回保險費。
如果合同訂立時，保險人已經知道投保人未如實告知的情況的，則保險人不得解除保險合同。如果發生保險事故，保險人應承擔賠償或者支付保險金的責任。
第十八條 — 地址或通知方式變更
如果投保人的居住地址或通信方式發生變更，則投保人應以書面通知形式及時告知保險人。如果投保人未能及時書面告知保險人，則保險人將通知寄送至投保人的最後已知地址時，視為通知已送達給投保人。
第十九條 — 保險事故通知
投保人、被保險人或者受益人知道保險事故發生後，應當及時通知保險人。故意或者因重大過失未及時通知，致使保險事故的性質、原因、損失程度等難以確定的，保險人對無法確定的部分，不承擔賠償或者給付保險金的責任，但保險人通過其他途徑已經及時知道或者應當及時知道保險事故發生的除外。
上述義務不包括由於不可抗力導致的延遲。
8. 保險賠償和支付
第二十條 — 理賠申請
向保險人提交理賠申請時，保險金申請人應出具以下材料。如果出於任何特殊原因導致申請人無法出具以下 材料，則應出具其他必需的法律材料或相關材料。如果因申請人無法提供材料而導致保險人無法確認理賠申請的真實性，則保險人不應承擔損失中無法確認部分的賠償責任：
a. 理賠申請表；
b. 保險單或其他保險憑證；
c. 申請人合法身份證明；
d. 醫院簽發的醫療收據（緊急治療醫療費用收據應蓋有醫院的緊急治療印章）、診斷證明和醫療記錄等資料的原始憑證；
e. 醫療轉運方面，應出具由保險人認可的合法救援組織簽發的書面證明文件；
f. 與損傷性質、原因和程度的確認等相關的其他支持文檔和信息。
第二十一條 — 保險金請求權的訴訟時效
申請人向保險人請求給付保險金的訴訟時效期間以現行有效的法律規定為準。
第二十二條 — 賠償原則
本保險合同的保障費用賠償，應按照以下賠償原則。
(1) 如被保險人已經從其它途徑（包括但不限於社會基本醫療保險、公費醫療保險、工作單位之醫療保險、
被保險人所持有任何商業保險機構之醫療保險）獲得相關醫療費用賠付，保險人僅需按被保險人從其他途徑
（包括但不限於社會基本醫療保險、公費醫療保險、工作單位之醫療保險、被保險人所持有任何商業保險機構之醫療保險）獲得醫療費用賠付後之餘額及保險合同條款進行賠付。
(2) 如被保險人是社會基本醫療保險或公費醫療保險之成員，但理賠時未能在社會基本醫療保險或公費醫療保險獲得賠償的，保險人將會按申請人保險憑證及保單保障權♛之保障上限及賠償標准進行賠付。
9. 爭端解决與適用法律
第二十三條 — 爭端解決
履行本保險合同期間產生的爭端應由有關各方通過協商解決。如果協商失敗，則各方均有權向中華人民共和國有管轄權的人民法院提起訴訟。
第二十四條 — 適用法律
本保險合同適用中華人民共和國法律（香港、澳門和台灣地區的相關法律除外）。
10. 其他條款
第二十五條 — 連續轉移條款
如果被保險人將現有其他保險單轉至本保險單，則保險人將維持被保險人在現有保險單項下所列明的承保條件或特約條款（例如延期償付或特別約定的責任免除事項等），且被保險人與保險人之間的保險合同也將受其約束。被保險人現有保險單的最早批單簽發日也將適用於本保險單， 任何保險單的轉移須以不增加本保險單所提供的保障為條件且須獲得保險人的書面同意。
當被保險人於保險人之團體醫療保險終止時，被保險人可以申請轉移至保險人之個人醫療保險項下的某一保險計劃。被保險人的該轉移申請須在其脫離團體醫療保險之前提交給保險人並須獲得保險人的書面同意方可被 接納。
第二十六條 — 合同的解除
投保人可在14日的猶豫期內聯繫保險人取消保險單。14日的猶豫期從本保險合同簽訂之日起計算，或從投保人收到全部的保險單條款和條件之日起計算，以兩者中較後者為準。14日猶豫期同樣也從每個續保日期起生效。如果投保人在猶豫期內沒有發生任何索賠或不存在任何在這14日內發生的可能導致索賠的情況，保險人應向
投保人退還投保人已繳納的保險費，同時投保人與保險人簽署的保險合同終止。如果在保險期間產生了符合條件
的理賠費用，則保險人保留在法律允許的範圍內向投保人要求支付為保險單提供的有關服務費用的權利，保險人有權從退回的保險費中扣除保險人就此發生的服務費用。
在本保險合同生效後，投保人可以以書面形式通知保險人解除本保險合同，但保險人已根據本保險合同規定支付保險金的，投保人不得要求解除本保險合同。
投保人在要求解除本保險合同時應出具以下證明和文件：
a. 保險單原件；
b. 保險費支付證明；
c. 投保人有效身份證明；
d. 投保人可提供的其他與本保險合同相關的任何文件。
本保險合同自保險人收到解除合同申請書及收齊相關證明和文件時起終止。在本保險合同終止後30天內，保險人將向投保人退回本保險合同的最低現金價值。
本保險合同的任何終止應不影響保險費已支付期間內各方應有的權利和應承擔的義務。
第二十七條 — 使用會員卡
1. 直接結算會員卡為保險人所有。此會員卡僅適用於被保險人接受符合本保險單條件的治療時，享受直接付費服務。
2. 任何情況下，被保險人在接受本條款第六條責任免除和/或保險憑證中列明的責任免除事項相關的治療時，不可以使用直接結算會員卡。保險人對其誤用此類直接結算會員卡的行為不承擔任何責任。
3. 如果被保險人通過門診直接結算選擇接受不符合本保險單條件的治療，被保險人作為第一責任人需要承擔由此產生的費用，且被保險人必須自保險人追償之日起，15個工作日內將保險人就此已支付的費用退還給保險人。保險人可從有效理賠保險金中抵扣被保險人到期應付而未付的款項，同時，保險人也可以中止 被保險人的保障直到被保險人全額支付其應付款項為止。
4. 如果保險人確定投保人、被保險人或受♛人使用任何欺詐的行為騙取保險金，則保險人有權解除本保險合同，且該終止將立即生效。被保險人必須自保險人追償之日起，15個工作日內將與此保險欺詐相關的理賠保險金退還給保險人。
5. 如果被保險人擁有直接結算會員卡，當投保人取消保險單或停止對保險單進行續保時，則應由投保人負責將被保險人(含連帶被保險人)的所有此類會員卡退還給保險人。保險人對被保險人在保障停止後誤用此 類直接結算會員卡的行為不承擔任何責任。
6. 若被保險人(包括連帶被保險人)的直接結算會員卡遺失，投保人應立即通知保險人。
7. 投保人應為被保險人的擔保人。任何被保險人未清償之款項，由投保人負責償還。
10. 其他條款
第二十八條 — 棄權
保險人放棄對違反本保險合同任何條款或條件的任何行為進行追究的權利不妨礙該條款或條件的後續執行，也不應視為對隨後的任何違反行為放棄追究的權利。
第二十九條 — 保險單管理
1. 投保人保證，如果出於任何原因導致本保險合同無法續保或本保險合同應根據上述第二十六條中的條款予以解除，則會立即告知其所有符合資格的員工，從而確保此類符合資格的員工知道保障已經解除，且對符合資格的員工或其家庭成員而言保險金無法支付。
2. 在職員工: 在職員工指投保人以全職、永久的方式聘用的直接被保險人，直接被保險人按照聘用條款以全職形式履行其所有常規職責。
如果直接被保險人是僱員，則直接被保險人在合格加入團體計劃的當天起需要保持在職狀態。如果直接被保險人在合格加入團體計劃的當天為非在職狀態，則該直接被保險人只能在其重返工作崗位及其恢復在職狀態的當天起享有團體計劃保障。直接被保險人只有其重返工作崗位時才能申請添加連帶被保險人。
如果出現以下任何的情況，直接被保險人被視為“非在職員工”:
• 直接被保險人的工作時間少於規定工作時間的80%，或者工資低於僱傭條款所規定正常工資的80%
• 直接被保險人因健康狀況需要離開正常工作場所60天以上，當地法規准許的產假/陪產假除外。
3. 由於本保險合同旨在為符合資格的員工和連帶被保險人提供保障，因此投保人保證將保險人送達投保人的任何更改後的保險條款或保障一覽表修訂版、或任何保險人送達投保人的與保障範圍有關的通知及時送交所有符合資格的員工。
4. 投保人應通知團體被保險人有關本團體保險單的條款和條件以及批註的任何變更。投保人還應通知團體被保險人有關本保險單與任何之前團體保險單相關的條款和條件的任何變更。
5. 投保人保證使保險人免於承擔因投保人未能履行本保險合同中自身義務而產生的成本、損失及開支。如果由於投保人未履行本保險合同第二十九條“保險單管理”的任何一項義務，導致保險人被索賠的，投保人將 賠償保險人由此產生的全部損失，包括但不限於爭端解決費用、保險賠償金、律師費以及其他一切費用。
6. 投保人應指定一名負責人員(即保險單管理員)根據本保險合同的條款以及保險人經常發布的指引來管理本保險合同，投保人並應以書面形式告知保險人有關指定人員的任何變更。
7. 保障中斷: 無論因何種原因導致的保障中斷，保險人均保留再次對投保前疾病使用責任免除6.26 的權利。
8. 儘管投保人已將有關本保險合同的全部或部分義務委託給應視為投保人代理人的中介或代理人，投保人仍應承擔本保險合同中投保人的義務和責任。
9. 如果投保人進入破產程序或指定了管理人、接收人或接管人對投保人的全部或部分業務或資產進行監管，則投保人應立即書面告知保險人。
10. 如果被保險人的地址或職業發生變更，則保險單管理員應立即書面告知保險人。
11. 通用條款
第三十條 — 通用條款
1. 保險人保留修改或終止團體保險單的權利，修改或終止從任意續保日期起生效。
2. 本保險合同的修改必須採用書面形式，並加蓋保險人印章，否則所作修改將不予承認。
3. 根據本保險合同送達的通知必須採用書面形式並通過郵遞或傳真機送達，如果是發送給保險人的通知，則應將郵件寄送到保險人註冊地址後視為已送達；如果使用傳真機寄送通知，則應將發送時間視為送達時間。
4. 保險人為解釋或實施投保人的被保險人文檔中的任何條款或條件而進行的任何修改均不妨礙該條款或條件隨後的實施，也不應被視為任何隨後的解釋或實施的先例。
5. 本保險合同若中文條款與英文條款存在不一致的，以中文條款為準。
1. 事故： 指保險期間在被保險人身上發生的突然的、意外的、不可預見的、非自願的、並對被保險人造成可識別的人身損傷的外部事件。
2. 急性的病症： 對旨在使被保險人恢復健康狀態的治療可能做出快速迴響的疾病、病症或損傷。且被保險人可完全康復至疾病、病症、損傷的因素出現以前的情況。
3. 恐怖主義行為： 指恐怖分子或恐怖組織為達到政治、軍事、社會或宗教目的而對平民採用隱蔽的暴力手段進行脅迫或恐嚇的舉動。
4. 周歲： 指按有效身份證件文件中記載的出生日期計算的年齡，自出生之日起為零周歲，每經過1年增加1歲，不足1年的不計。
5. 結算協議： 保險人與時康國際公司公佈的醫療機構網絡中列明的每一家醫院、日間看護所或掃描中心之間達成的協議。
6. 替代療法： 指在醫療機構以外採用傳統醫學進行治療和診斷的治療。此類醫學包括由具備 資質的理療師提供的整脊治療、手足病治療和足病治療、整骨療法、飲食療法、順勢療法和針灸療法。
7. 根尖切除術： 指為牙齒移除根尖及附近受感染組織而進行的牙科手術，牙齒雖經過根管手術，但其末端的骨質區仍存在炎症和感染的牙槽膿腫。進行根尖切除術是為了治療 以下病症：
－ 齒根斷裂；
－ 齒根嚴重彎曲；
－ 牙齒上有牙帽或牙樁；
－ 根管治療無法治癒的囊腫或感染；
－ 根管穿孔；
－ 反復發作的疼痛和感染；
－ 無法通過X光確定問題根源的持續症狀；
－ 鈣化；
－ 需要進行手術的牙根表面和周圍骨質的損傷。
8. 保障區域： 預設保障區域為全球(不包括美國)，即保險人提供全球符合保障範圍的保障， 但不包括在美國的任何選擇性治療。如預設保障區域為全球(不包括美國)，保障區域以外是指美國。如投保人選擇“中國大陸選擇”的保障項目，保障區域則為中國大陸(不包括香港、澳門、台灣 －下同)，保障區域以外是指中國大陸以外的區域。
9. 保障： 本保險單和保險憑證中列明的任何擴展條款或限制、或任何批註（如果可用）中提供的保險保障，這些保障均以保險人收到應付的保險費為前提。
10. 保障一覽表： 適用於本保險單並列明保險人應支付的最高保障限額。
11. 癌症： 指惡性腫瘤、組織或細胞，其特徵是惡性細胞不受控制地生長、蔓延並侵入到組織中。
12. 保險憑証： 指由保險人提供格式的，列明被保險人、保險期間、保險人、批單簽發日、保障等級和任何適用批註的保險單詳情的證明。
13. 先天性疾病： 指一出生就顯現的或被認為自出生開始就存在的一種醫療狀況，無論該醫療狀況是遺傳的還是受環境因素影響。
14. 自付比例： 指被保險人在對費用進行理賠時，應由自己支付的理賠費用中的不保費用部分。
15. 國籍國： 指被保險人持有其合法護照的國家。
16. 居住國： 被保險人在保險單生效日期或批單簽發日或隨後的每一個續保日期習慣性居住的國家（在每個保險期間內通常不少於6個月）。
17. 慢性疾病： 至少擁有以下特征之一的疾病、病症或損傷：
－ 需要通過咨詢、檢查、體檢、藥物和敷料和/或實驗室檢查進行持續或長期監控；
－ 需要持續或長期控制症狀或緩解症狀；
－ 需要被保險人進行康復治療或接受特別培訓以應對疾病；
－ 持續時間不定；
－ 尚未有已知治愈方法；
－ 會復發或可能複發。
18. 日間留院患者： 由於康復需要一段時間的醫療監控而在醫院或日間看護所住院、但不會佔用醫院床位過夜的患者。
19. 免賠額： 被保險人的保險憑證中指明、在根據保險單支付住院，日間留院或門診保障以前應由被保險人支付的不保金額。保險單免賠額適用於每名被保險人的每個保險 期間。
20. 牙科醫生： 在提供牙科治療的所在國家/地區擁有由相關許可機構頒發的許可、可以合法從事牙科治療的人士。
21. 連帶被保險人： 在保險合同生效日期或隨後的任何續保日期與被保險人居住在一起的配偶、成年 伴侶、或18周歲以下的未婚子女、或接受全日制教育的28周歲以下的子女（需要提供其註冊教育機構出具的書面證明）。 術語“伴侶”可能指丈夫、妻子或以類似關係和被保險人永久居住在一起的人士。所有受養人均應在保險憑證中被稱為連帶被保險人。
22. 診斷檢查： 為查明或幫助查明被保險人的病因而進行的調查，例如X光或♛檢。
23. 藥物和敷料： 由醫生或專科醫生開具的、為減輕或治療某一個醫療狀況所必須的基本處方藥、敷料和藥物。
24. 符合保障范圍： 被保險人的保險單覆蓋的治療和費用。為確定治療或費用是否在覆蓋範圍內，應一同閱讀被保險人保險單的所有章節，並應遵守保險單列明的所有條款(包括應付保險費的支付）、保障和責任免除。
25. 批單簽發日： 在保險憑證中列明的、被保險人被本保險單接納的日期。
26. 轉運或送返： 將被保險人轉移至擁有必要住院及日間留院送返服務醫療設施的醫院，醫療機構可以位於被保險人生病時所在的國家，也可位於另一個鄰近國家(轉運)、 或將被保險人送回被保險人的主要國籍國或被保險人的主要居住國(送返)。 服務內容包括由保險人在轉移被保險人時指定的國際救援公司認可的所有醫療上必需的治療。
27. 排除在外的國家： 指的是我們無法為您提供保障的國家列表(如果您居住在其中任何一個排除在外的國家)。有關我們的排除在外國家/地區列表的詳細信息，請聯繫我們的客戶服務 團隊。
28. 外國國籍的人士： 在其持有合法護照的國家以外的國家/地區居住和/或生活的所有人士。通常居住和/或生活的時間為每個保險期間內超過180日。
29. 地理區域： 用於在本保險合同的生效日期或任何後續的續保日期根據被保險人的主要居住國計算適用於被保險人的保險費的地理區域。
30. 昂貴醫療服務機構名單： 保險人排除在承保範圍之外的醫療服務機構名單。保險公司不承保被保險人在昂貴醫療服務機構名單中所產生的任何治療費用。保險公司將定期更新昂貴醫療服務機構名單。有關保險公司的昂貴醫療服務機構名單的詳細信息，被保險人可以聯繫保險公司的客戶服務團隊。
31. 醫院： 經其經營所在國家/地區的法律許可註冊為醫院或外科醫院的任何機構。以下機構不視為醫院：休養護理院、水療中心和療養勝地等機構。
32. 醫院牀位： 指保障一覽表中列明的標准單人病房或雙人病房。豪華病房、行政病房和特需套房不包括在內。
33. 網內醫療機構： 網內醫療機構指與被保險人之保險單已簽訂合同，並按預先商定的特定費率為保險單的被保險人提供服務的醫療機構。
34. 入院患者： 出於醫學原因被醫院接收，並在病床上待上一夜或更長時間的患者。
35. 被保險人/你/你的： 本保險單提供保障的、在保險憑證中提及的符合資格的被保險人和/或連帶被保險人。
36. 保險人： 亞太財產保險有限公司。
37. 醫療狀況： 任何疾病、損傷或病症，包括精神疾病。
38. 醫生： 在WHO 認可的醫學院校就讀並獲得藥物或手術初級學位，並獲得提供治療所在國家/地區的相關權威機構之行醫資質的人士。術語“認可的醫學院校”指列在 WHO 公佈的世界醫學院校名錄中的醫學院校。
39. 醫療上必需的治療： 指符合資格的醫生認為適當的、與診斷一致的、根據一般公認的醫學標準不能被忽略的、一旦忽略將對被保險人的病症或施與的醫療護理造成負面影響的相關 治療。提供此類治療時不能只考慮到患者或醫生的舒適方便，且只能持續提供 一段時間。“適當”用於此定義中時是指充分考慮患者的安全和經濟效益。
當特指住院治療時，醫療上必需的還指診斷無法執行或門診治療無法安全和有效
地提供。
40. 新生嬰兒： 出生時間為16 週以內的嬰兒。
41. 醫療網絡/
時康國際醫療網絡： 保險人/保單管理人公佈的與其簽有直接結算協議的醫療機構網絡。
42. 網絡外醫療機構： 網絡外醫療機構是未與被保險人的保險單簽訂合同的醫療機構。
43. 門診患者： 前往醫院、診療室、門診診所或進行遠程醫療治療，但不需要被接納為日間留院或住院的患者。
44. 門診直接結算： 保險人公佈的與其簽有直接結算協議的醫療機構網絡。
45. 門診每次就診免賠額： 被保險人的保險憑證中指明、在根據保險單支付門診保障以前應由被保險人支付的不保金額。每次就診均視為一次諮詢。門診每次就診免賠額適用於每名被保險人的每一次門診諮詢。
46. 保險期間： 約定起保日的零時開始到約定期滿日24 小時止通常為期12 個月的一段時間。
47. 物理治療師： 在提供治療的國家/地區註冊並獲得執業許可的執業物理治療師。
48. 預先書面同意： 指被保險人在接受任何治療或承擔任何費用前從保險人處尋求審批的流程。需要保險人預先書面同意的保障將會在保障一覽表中註明需預先書面同意。
49. 計劃： 您與我們之間的合同，其中列出所提供保障的條款和條件。完整的保障條款和條件包括申請表、保險單、福利表和本會員手冊。
50. 投保人： 在保險單或保險憑證中被稱為投保人的團體。
51. 懷孕： 指從首次確診到分娩的一段時間。
52. 主醫療保險單： 如果被保險人擁有不止一份健康保險單，則這是指最先支付理賠的健康保險單。
53. 主醫療之保險人： 主醫療保險單的保險人。
54. 私人病房： 私人醫院中只設有一張床位的病房。豪華病房、行政病房和特需套房不包括在內。
55. 精神疾病： 符合精神疾病診斷與統計手冊(DSM) 或國際疾病分類(ICD) 等國際分類系統的分類標準的精神或神經紊亂。紊亂應與個人當前的痛苦或其進行重要日常活動 (例如工作) 能力的嚴重受損有關。上述病症必須具有顯著的臨床表現，而不僅是由
某一特定事件造成的預期反應，例如喪親之痛、人際關係或學術問題，以及文化
適應等。
56. 合格護士： 目前在提供治療的國家/地區的任何法定護士登記機構管理的或護士名冊上有登記的護士。
57. 合理及慣常收費： 在被保險人接受治療的國家/地區根據被保險人的慣常收費治療費用通常應收取 的費用。保險人有權要求獨立的第三方對此類費用進行證實，例如執業外科醫生/醫生/專科醫生或政府衛生部門/易全保綜合醫療網絡等。
58. 最低現金價值： 1) 保險生效日前退保的，最低現金價值=投保人已交納保險費。
2) 保險生效日後退保的，若保險費為一次性支付的：
最低現金價值=淨保費×(1-m/n)，其中，m為已生效天數，n為保險期間的天數，經過日期不足一日的按一日計算。淨保費=投保人已交納保險費×(1-費用比例)，除另有約定外，費用比例為15%。
3) 等待期後退保的，若保險費為分期支付的：
最低現金價值=當月淨保費×(1-m/n)，其中，m為當月已生效天數，n為當月的總天數，經過日期不足一日的按一日計算。當月淨保費=投保人已交納當月
保險費×(1-費用比例)，除另有約定外，費用比例為15%。
59. 康復治療： 醫療上必需的治療，旨在使被保險人經受某一醫療狀況後恢復在日常生活中獨立行動的能力及其正常機能。
60. 相關醫療狀況： 相關醫療狀況是指由已存在的醫療狀況所導致或與已存在的醫療狀況由同一原因導致的任何疾病、損傷或病症，包括精神疾病。
61. 續保日期： 指保險單的生效日期的周年對應日。
62. 二級醫療保險： 如果被保險人擁有一份以上的健康保險保單，則二級醫療保險是在主醫療保險 支付其部分後支付理賠的付款人。如果被保險人擁有超過一份健康保險單，則該保險單將是最後支付的健康保險單。如果被保險人購買本保險單作為二級醫療 保險單，保險人將僅在以下情況下支付理賠：
－ 索賠已提交給主醫療保險公司，但由於不符合資格或主醫療保險合同規定的福利限額已用盡，索賠未支付/未完全支付索賠的金額，並且
－ 未支付的索賠金額被視為本保單下的合格索賠。
被保險人投保本保險時，需提供被保險人主醫療保險的保險憑證複印件。在任何情況下，我們只會支付主醫療保險未賠付的合格索賠金額的餘額。
63. 雙人病房： 私人醫院中設有兩張床位的病房。豪華病房、行政病房和特需套房不包括在內。
64. 易全保綜合醫療網絡： 如果被保險人已將保障區域擴展到全球(不包括美國)，則保險人的醫療提供者名單可提供給被保險人。
65. 專科醫生： 在WHO 認可的醫學院校就讀並獲得藥物或手術初級學位，並獲得提供治療所在國家/地區的相關權威機構之行醫資質的外科醫生、麻醉師或醫生，並被認為在所治療的疾病、病症或損傷的治療領域擁有專業資格或專業技術。術語“認可的醫學院校”指列在WHO 公佈的世界醫學院校名錄中的醫學院校。
66. 生效日期： 保險憑證中顯示的保險單生效日期。
67. 外科手術： 需要切開組織並進行其他侵入性手術干預的手術。
68. 終末期疾病： 得出病症為終末期和無藥可救的診斷，且無法對病症進行治愈治療，並且確診後12 個月內可能死亡。
69. 治療： 診斷、緩解、治愈某一個醫療狀況所必需的手術或醫療服務（包括診斷檢查）。
70. 疫苗： 指提供治療的國家/地區法律所規定的全部基本免疫疫苗和加強藥物注射，包括醫療上必需的任何旅行疫苗和瘧疾預防。
71. 等待期： 指從保險單生效日或批單簽發日（二者以後發生日為準）後的一定時期。在等待期內，保險人不承擔某項特定保險責任。等待期結束後，該項保險責任才正式
生效。
72. 團體： 在中國境內成立的不以購買保險為目的的合法機構，包括國有企業、高等院校、企事業單位、貿易組織和職業聯盟等。
73. 緊急： 突然的、嚴重的、不可預見的急性醫療狀況或需要立即進行醫學治療的損傷，如果不接受治療，在未來48 小時可能導致死亡或對身體機能造成嚴重損害。
74. WHO： 世界衛生組織。
二. 亞太財產保險有限公司
易全保團體醫療保險(2024年4月版): 保障一覽表
本保障一覽表僅供參考。詳情請參閱保險合同條款。
保障 | 易全保琥珀 |
年度最高保障限額 所有計劃均提供24/7熱線和援助服務 | 6,300,000人民幣 |
保障區域: | 全球保障 （不含美國） |
指定網絡: | 易全保綜合醫療網絡 |
1. 醫院收費、醫生和專科醫生費用 | a) 全額賠償 上述保障需要預先獲得書面同意 🕿 b) 每個醫療狀況 最高限額9,450人民幣 |
a) 醫院對住院或日間留院治療的患者收取的費用包括：床位費（一般病房/雙人病房或私人病房）；診斷檢測費用；手術室費用（含外科醫生與麻醉師收費）；合格護士護理的費用；由醫生或專科醫生開具的藥物和敷料的費用；手術期間醫生使用的手術器械費用；住院或日間留院期間手術前後的咨詢費；重症監護費用。 | |
b) 輔助器材費用：屬於保障范圍內並因醫療所需，在住院或日間留院接受治療的6個月內，用於購買及租賃拐杖、支撐架、輔助行走器和自推式非ℝ子輪椅的費用。 | |
2. 診斷程序 保險人應賠付由醫療必需而引致的實際醫療費用，包括：磁共振成象掃描(MRI)、正ℝ子放射斷層掃描(PET)和計算機斷層成像掃描(CT)的費用。 3. 腎衰竭和腎透析 a) 保險人應賠付被保險人住院接受腎衰竭(包括腎透析)治療時實際產生的醫療費用。 b) 保險人應賠付被保險人日間留院或在門診部接受腎衰竭(包括腎透析)治療時實際產生的醫療費用。 4. 器官移植 被保險人是器官受贈人時，有關腎臟、胰臟、肝臟、心臟、肺、骨髓、角膜的人體器官移植治療時產生的醫療費用。 當器官移植是由先天性疾病導致時，相關醫療費用應當依照本保險合同第五條項下第7款(先天性疾病)進行賠付，此時本保險合同第五條項下第4款(器官移植)對於相關費用一概不予賠付。 保險人僅賠付滿足以下條件的器官移植：在國際認可的醫院並由獲得認證的外科醫生執行器官移植；並根據WHO指南獲取的器官。 器官捐獻者和尋找器官捐獻者的相關醫療費用一概不予賠付。 5. 癌症治療 保險人應賠付因癌症而須住院﹑日間留院或門診治療時實際產生的醫療費用。此保障包括從診斷之時起，產生的腫瘤科醫生的費用﹑手術費用，放射療法和化學療法的單項或綜合費用。 | 住院前和手術後掃描全額賠償 |
磁共振成像掃描(MRI)、 正電子放射斷層掃描(PET)和計算機斷層成像掃描(CT)，需要預先獲得書面同意 🕿 | |
a) | |
住院手術前後治療 每個保險期內最高達6周 全額賠償 | |
b) | |
日間留院或門診治療每個保險期內 最高限額310,000人民幣 | |
每個保險期內 最高限額630,000人民幣 | |
全額賠償 |
全額賠償 不予承保
有限承保
可供選項
保障 | 易全保琥珀 |
6. 新生嬰兒保障 | |
保險人應賠付被保險人的新生嬰兒因早產（即妊娠未滿37週分娩）或被保險人的新生嬰兒在出生 30日內出現急性的病症而需住院接受治療時而發生的實際醫療費用。 | |
此保障提供的前提是新生嬰兒在出生之日起30日內已經加入本保險合同並且投保人已支付保險費。 此保障經投保人和保險人雙方同意可適用於多胎分娩的情況。 如果保險人在嬰兒被加入保單之前需要詳細了解新生嬰兒的病史，則保險人保留其對所提供承保範圍應用特別限制條款的權利。 | 每個保險期內 最高限額157,500人民幣 |
請參閱第3條條款 － 新增新生嬰兒保單條款有關詳細信息。 | |
7. 先天性疾病 保險人應賠付被保險人因先天性疾病進行住院治療時實際產生的醫療費用。若新生嬰兒出生30日內因先天性疾病接受治療，將根據本保險合同第五條第6款 – 新生嬰兒保障規定提供此類病症的 保障，而本條款先天性疾病保障則不適用。最高保障限額應經投保人與保險人雙方同意，並在保險 合同中列明。 8. 家長住宿費用 保險人應賠付18周歲以下的被保險人因接受符合保障范圍內的住院治療時，其一位家長在醫院陪伴過夜而實際產生的住宿費用。 9. 新生嬰兒陪伴母親的醫院住宿費用 保險人應賠付新生嬰兒(出生16周及以下)在陪伴母親(母親為被保險人)接受住院治療符合保障范圍內的疾病時，醫院為新生嬰兒提供住宿而產生的實際費用。 10. 整形外科手術 保險人應賠付被保險人接受整形外科手術的實際醫療費用，此整形外科手術是為了恢復正常人體的功能或外貌，同時此整形外科手術是因被保險人在保險單生效日或批單簽發日(二者以後發生日為準)之後遭遇符合本保險合同保障範圍的意外事故或因接受符合本保險合同保障範圍內的疾病而接受了外科手術後產生。 11. 日間留院和門診手術 保險人應賠付被保險人在外科診所﹑醫院﹑日間護理中心或門診部進行的外科手術時實際產生的治療費用。 12. 緊急住院牙科治療 被保險人因遭遇意外事故后而必須住院一晚以上，其天然健全的牙齒因需進行緊急牙科修復治療，保險人應按實際發生的醫療費用賠付給被保險人。 該牙科治療必須在意外事故發生后的10日內進行。此保障包括因意外的外部撞擊造成的口腔傷害而須接受治療時產生的所有費用，但同時應滿足以下條件： a) 如果上述治療涉及更換齒冠、牙橋貼片、牙齒貼面或假牙，則保險人賠付合理慣常的費用，或賠付類似的或質量相當的更換費用； b) 如果臨床角度上需要植牙，那麼保險人賠付採用橋托產生的費用； c) 修復或重建在遭遇意外事故後損壞的假牙，但要求被保險人在遭遇意外事故時佩戴此類假牙。 13. 康復治療 專科醫生針對被保險人所患疾病進行治療時，推薦被保險人接受保險人認可的醫院康復中心接受 住院康復治療，保險人應賠付此種情況下實際產生的康復治療費用。但必須：被保險人連續三日 住院；專科醫生書面確認被保險人此時有必要接受康復治療。應在出院後14日內辦妥康復中心住院手續。上述治療應接受專科醫生的直接監管，並賠付如下費用： a) 專項治療病房的使用費； b) 物理治療費用； c) 語障治療費用； d) 職業病治療費用。 14. 家居護理 由醫生或專科醫生推薦，在被保險人接受住院或日間留院治療後，由合格護士在被保險人家中提供護理的費用。 此保障必須預先獲得保險人書面同意。 | 每個保險期內 最高限額157,500人民幣 |
全額賠償 | |
全額賠償 | |
全額賠償 | |
全額賠償 | |
全額賠償 | |
符合保障範圍的住院治療每個醫療狀況 最高達30日全額賠償 | |
不予承保 |
保障 | 易全保琥珀 |
15. 緊急救護運送費用 保險人應賠付陸上緊急救護交通運輸工具接送或在醫院之間轉送途中，或經醫生或專科醫生認為醫療必需的交通運輸工具實際產生的費用。 | 全額賠償 |
16. 轉運和送返 a) 轉運 保險人安排患有符合保障范圍內的危重被保險人運送到最近的醫療機構進行住院或日間留院治療。 賠付如下合理費用： i) 在被保險人須接受緊急治療而事故發生地無法提供醫療上必需的救護接送與護理的情況下，運送被保險人時產生的交通費用。其中包括一名隨行照料人員陪護行程中的經濟艙機票。 ii) 被保險人在接受日間留院治療期間，往返醫院赴診時的當地合理交通費用。 iii) 被保險人入院后隨行照料人員由於看望被保險人往返醫院時產生的合理交通費用。 iv) 僅限住院前或出院后短期內，被保險人接受專科醫生護理時的合理非醫院住宿費用。 在保險人認可的滑雪場或類似的冬季運動場所範圍之外，進行任何海空營救或山地救援時產生的轉運費用一概不予賠付。 保險人的醫學顧問將決定轉運時的最合適的交通方式。如違背保險人醫學顧問的意見，保險人 不賠付交通費用。另外，如果被保險人前往的醫院不具備合適醫療設施用以治療被保險人之符合保障范圍的醫療情況，則相關的交通費用將不予賠付。 b) 送返 經由醫療上必需且由保險人安排的轉運之後，在被保險人完成治療後的一個月內，在治療地的被保險人與被保險人的一位隨行照料人員將可獲安排經濟艙機票返回被保險人的國籍國或 居住國。 需要已經完成最初的醫療上必需的轉運，才可賠付此交通費用。 免賠額適用於此計劃保障。 17. 遺體運送 保險人應賠付被保險人因保障范圍內的醫療狀況導致死亡時產生以下合理和慣常的費用： a) 將被保險人遺體或骨灰運往其國籍國或居住國時的費用，或 b) 在被保險人死亡所在地，根據合理的慣例進行土葬或火葬時產生的費用。 18. 保障區域以外的緊急非選擇性治療 – 在不超過30日(含30日)的計劃行程 被保險人在保障區域以外若遇到意外事故或因某種突發性醫療狀況而形成對被保險人的健康構成威脅的突發危重疾病，而且其在上述緊急事件之後的24小時內接受醫生或專科醫生提供的治療，則保險人應賠付該期間實際產生的醫療費用。 19. 住院現金津貼 保險人應賠付被保險人在醫院接受住院治療期間每一晚的現金住院津貼，但應滿足以下條件： a) 被保險人在零時前於居住國家的公立醫院接受選擇性住院治療；或 b) 該計劃是二級醫療保險計劃。但是，如果被保險人的計劃免賠額是人民幣63,000或人民幣94,500，被保險人不可享用此保障。 該保障僅限於每個保險期間內累計最長不超過30晚(含30晚)。責任免除6.9條款並不適用於此保障。 | 綜合最高限額630,000人民幣 該保障需要預先獲得書面同意🕿 a) 轉運 i) 全額賠償 ii) 全額賠償 iii) 全額賠償 iv) 每日最高限額 1,200人民幣 每人每次轉運最高限額 47,000人民幣 該保障需要預先獲得書面同意🕿 b) 送返 全額賠償 該保障需要預先獲得書面同意🕿 a) 全額賠償 b) 最高限額63,000人民幣 意外：意外後的住院和日間留院治療全額賠償 疾病：住院和日間留院護理 每個保險期內 最高限額157,500人民幣 每晚最高限額790人民幣 |
保障 | 易全保琥珀 |
年度門診限額： 適用於保險合同第20款和21款，受年度最高保險計劃限額限制。 | 每個保險期內 每個醫療狀況手術前的門診醫生費用， 從入院前的15日至 出院後最長30日內的門診費用，最高限額 4,700人民幣。 |
20. 門診醫生費用 a) 含括諮詢費在內的醫生收費，專科醫生費用，診斷檢查費用； b) 遠程醫療諮詢(醫生以ℝ子方式進行遠程醫療諮詢)； 如果被保險人在時康國際公佈的易全保綜合醫療網絡內列明的醫療服務提供方接受治療，符合保障範圍內的治療費用將全額賠付。 如果被保險人不是在時康國際公佈的易全保綜合醫療網絡內列明的醫療服務提供方接受治療，則只會賠付符合保障範圍內合理和慣常的醫療費用。 c) 處方藥和敷料的費用； d) 維生素和礦物質。 由醫生開具的維生素和礦物質。按照門診福利保障為維生素缺乏症確診者賠付由醫生開具的維生素。 任何手術前和出院後的門診費用將根據此保障進行賠付。 被保險人的保障範圍不包括被保險人因調理慢性疾病而承擔的費用。如果被保險人根據易全保翡翠計劃，易全保水晶計劃保險單選項投保則保險人將在本保險合同第五條項下第20款門診醫生費用承擔調理慢性疾病的治療費用。 請注意：如果索賠收據未顯示所提供醫療服務的明細，我們將僅支付不超過處方藥和敷料限額的符合條件的索賠。 年度門診限額：適用於保險合同第20款和21款，受年度最高保險計劃限額限制。 | a) 和 b) 每個保險期內 每個醫療狀況手術前的門診醫生費用， 從入院前的15日至 出院後最長30日內的門診費用，最高限額 4,700人民幣 c) 不予承保 d) 不予承保 a), b), c), d) 受年度最高門診限額限制。 |
21. 門診物理治療和替代療法 保險人應賠付以下項目實際產生的醫療費用： a) 由獲得執業許可的物理治療師提供的物理治療費用。 b) 被保險人接受理療師的輔助藥物和治療，此類賠償可包括整骨療法﹑手足病治療和足病治療﹑整脊療法﹑順勢療法﹑飲食療法和針灸療法的費用。 c) 中醫執業醫師或阿育吠陀醫學執業醫師對被保險人進行門診治療時實際產生的醫療費用。 保險期內您可選擇此保障a)或b)，合計首5次治療不需轉介(飲食療法除外)，其他後續治療需醫生或專科醫生轉介。 年度門診限額：適用於保險合同第20款和21款，受年度最高保險計劃限額限制。 | 不予承保 |
保障 | 易全保琥珀 |
22. 更年期激素替代治療 需要進行激素替代治療以緩解更年期早發症狀之門診費用，但更年期發病和治療須始於40歲以下。 | 不予承保 |
23. 門診精神疾病治療 | |
由法定資質的心理學家及/或法定資質的精神病醫生的直接管理下，被保險人接受的門診治療。此項保障包括10次治療，賠付費用以本保障限額為準。 前5次就診無需醫生轉介，之後的就診則需要有醫生或專科醫生的轉介函和治療計劃。 | 不予承保 |
24. 牙科 | |
保險人應賠付以下項目實際產生的醫療費用： | |
牙科治療：牙科執業醫生在牙科手術期間/牙科診所進行牙科治療的費用。牙科治療包括： | |
－ 牙齒檢查(若有必要其中包括照牙科X光)； | |
－ 預防性洗牙，拋光和窩溝封閉(每年一次)； | |
－ 補牙和拔牙(非手術和手術性)； | |
－ 根管治療 ； | 不予承保 |
－ 新裝或修復牙冠，假牙，嵌體和牙橋； | |
－ 進行牙根尖切除術。 | |
不包括種植牙和牙齒矯正治療保障。 | |
其他牙科治療一概不屬於此類保障。 | |
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。 | |
此保障有20%的自付比例。 | |
免賠額或門診每次就診免賠額並不適用於此保障。 |
附加選項 | 易全保琥珀 |
25. 中國大陸選擇 | |
保險人應賠付被保險人在中國大陸因住院﹑日間留院及接受門診治療時實際產生的符合保障范圍的醫療費用。標准的保險單保障限額適用於本條。 中國大陸以外的緊急非選擇性治療： | 可供選項 |
在最長期限為30日的計劃行程中，被保險人若在中國大陸以外的地區遇到意外事故或因某種突發性醫療狀況而引致對其健康構成即時威脅的嚴重疾病，在上述緊急事件之後的24小時內接受的醫生或專科醫生提供的治療。 因意外事故，需接受住院和日間留院治療，保險人應全額賠付。 | 中國大陸以外的緊急非選擇性治療， 因疾病治療的最高限額 150,000人民幣 |
因疾病需接受住院和日間留院治療，以投保人和保險人雙方同意的最高保障限額為限。最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。 | |
26. 病房限制(住宿最高限額800人民幣) 如本保險合同第五條項下第1款(a)項所述，被保險人在中國大陸住院時，每日最高限額800人民幣，從而在中國大陸醫院接受保障範圍內的住院或日間留院治療及任何醫生的治療。醫院的定義及範圍由保險人事先約定。 27. 昂貴醫院限制 保險人將事先指定某些提供住院﹑日間留院或門診治療服務的醫療機構為昂貴醫院。被保險人在中國大陸任何一家昂貴醫院接受承保范圍內的住院﹑日間留院或門診治療及任何醫學專家的 治療時，保險人將不會賠付實際產生的有關醫療費用。 28. 私人医院住院自付比例 對屬於保障範圍內在私人醫院的住院或日間留院治療時實際產生的醫療費用，被保險人需承擔 20%自付比例。 29. 年度最高保障限額1,000,000人民幣 在本保險合同的保險期間內，如果發生了本保險合同涵蓋的醫療事項，保險人應支付保險金額 不得超過相應的保障限額，且支付的總保險金金額不得超過本保險合同中規定的年度最高保障限額 1,000,000人民幣。 30. 門診費用的自付比例 保險人應賠付被保險人符合保障範圍內的門診治療實際產生的醫療費用，但門診治療有 20%的自付比例。 自付比例並不適用於以下項目：癌症治療﹑器官移植﹑腎衰竭和腎透析。但此項不適用於6,300人民幣免賠額或更高免賠額之計劃。 如果被保險人的保險單中含有生育保障﹑牙科保障或體檢﹑疫苗保障，其相應的自付額將會在被保險人的保障一覽表中列明。 31. 門診每次就診免賠額 被保險人接受屬於保障範圍的門診治療時，門診每次就診設有150人民幣免賠額。 門診每次就診免賠額適用於本保險合同第五條第20款(門診醫生費用)和21款(門診物理治療和替代療法) 。 但此項不適用於6,300人民幣免賠額或更高免賠額之計劃。 32. 取消藥物和敷料限額 通過選擇此選項，保障 20 c) 下的處方藥和敷料將全額賠償，但受年度最高門診限額限制。適用於3名員工或以上的統一投保的團體保險單。 | 可供選項 |
於中國大陸醫院 接受住院或日間留院治療每日最高限額800人民幣 | |
可供選項 | |
可供選項 | |
20%自付比例 | |
可供選項 | |
不予承保 | |
不予承保 | |
不予承保 |
附加選項 | 易全保琥珀 | |
33. 體檢和疫苗 – 選項1 適用於3名員工或以上的統一投保的團體保險單。 a) 體檢保障：保險人應賠付例行健康檢查，包括癌症篩查、乳腺癌1號和2號基因檢查(如直系家屬有病史)、骨密度檢查(50周歲以上女性被保險人每5年可做1次)、心♛管系統檢查，神經系統 檢查、生命體徵檢查(例如，♛壓、體重指數、尿分析和膽固醇)、兒童體檢(至5周歲)的費用 和/或 b) 疫苗保障：醫療必需的免疫疫苗和加強藥物注射，以及醫療必需的任何旅行疫苗和瘧疾預防注射，保險人將賠付相關藥物費用和咨詢費用。 責任免除6.9條款並不適用於此保障。 | a) b) | 不予承保 不予承保 |
34. 體檢和疫苗 – 選項2 | a) b) a) b) | 不予承保 不予承保 不予承保 不予承保 |
適用於3名員工或以上的統一投保的團體保險單。 | ||
a) 體檢保障：保險人應賠付例行健康檢查，包括癌症篩查、乳腺癌1號和2號基因檢查(如直系家屬有病史)、骨密度檢查(50周歲以上女性被保險人每5年可做1次)、心♛管系統檢查，神經系統 檢查、生命體徵檢查(例如，♛壓、體重指數、尿分析和膽固醇)、兒童體檢(至5周歲)的費用 和/或 | ||
b) 疫苗保障：醫療必需的免疫疫苗和加強藥物注射，以及醫療必需的任何旅行疫苗和瘧疾預防注射，保險人將賠付相關藥物費用和咨詢費用。 | ||
責任免除6.9條款並不適用於此保障。 | ||
35. 生育保障 – 選項1 | ||
a) 被保險人懷孕或分娩期間實際產生的醫療必需費用；包括分娩費用、產前與產後六週內檢查、掃描、自然分娩或自願/緊急剖腹產的費用。本保障亦包含出生24小時內兒科醫生就新生嬰兒 首次檢查/體檢的收費，以及幼兒1週歲生日前由醫生或專科醫生建議的兒科健康檢查費用，包括體格檢查，身高體重頭圍胸圍等測量，視力聽力等感知覺篩查，智能心理評估，生長發育檢查，遺傳病及代謝疾病篩查，疫苗注射，尿檢，結核試驗，♛球容積比，♛紅蛋白及其他♛液檢查， 包括鐮狀細胞貧♛的篩查。 | ||
請注意此新生嬰兒檢查的費用保障，僅限於保險人已賠付本團體計劃下被保險人的分娩費用，且新生嬰兒已加入此團體計劃並成為被保險人時，保險人才會賠付上述新生嬰兒檢查的費用。 | ||
b) 對於產前期間因保障範圍內的醫療狀況所產生的實際住院治療費用或分娩期間因保障範圍內的醫療狀況所產生的實際住院治療費用，保險人僅將治療以下醫療狀況視為此福利保障b)中符合保障範圍內的醫療狀況。 | ||
－ 子宮外孕(胚胎在子宮以外的部位著床發育)； | ||
－ 葡萄胎(異常細胞在子宮內生長)； | ||
－ 胎盤滯留(胚胎滯留在子宮內)； | ||
－ 前置胎盤； | ||
－ 子癇(懷孕期間發生在先兆子癇之後的昏迷或抽搐)； | ||
－ 糖尿病(如果被保險人因自身與糖尿病有關的過往病史而有相應的責任免除，則被保險人不會因懷孕期間進行的任何糖尿病治療而獲得賠償)； | ||
－ 產後出♛(分娩後多個小時及多日大出♛)； | ||
－ 需要實時接受外科治療的流產。 | ||
本保障b)不包括自願/緊急剖腹產或“產程進展不良”的費用，除非是上述保障b)所列之符合保障範圍內的醫療狀況之一。 | ||
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。在第180日後至保單生效 一年期間產生的費用，此保障有95%的自付比例。不管投保人續保與否，被保險人必須完成180日 等待期才可賠付此保障。 | ||
因這是個人選擇，保險人對於育兒或其他相關課程一概不予賠付。 | ||
適用於10名或以上的團體保單。 | ||
責任免除6.27條款並不適用於此保障。 | ||
免賠額適用於此保障。 | ||
附加選項 | 易全保琥珀 | |
36. 生育保障 – 選項2 | a) b) | 不予承保 不予承保 |
a) 被保險人懷孕或分娩期間實際產生的醫療必需費用；包括分娩費用、產前與產後六週內檢查、掃描、自然分娩或自願/緊急剖腹產的費用。本保障亦包含出生24小時內兒科醫生就新生嬰兒 首次檢查/體檢的收費，以及幼兒1週歲生日前由醫生或專科醫生建議的兒科健康檢查費用，包括體格檢查，身高體重頭圍胸圍等測量，視力聽力等感知覺篩查，智能心理評估，生長發育檢查，遺傳病及代謝疾病篩查，疫苗注射，尿檢，結核試驗，♛球容積比，♛紅蛋白及其他♛液檢查， 包括鐮狀細胞貧♛的篩查。 | ||
請注意此新生嬰兒檢查的費用保障，僅限於保險人已賠付本團體計劃下被保險人的分娩費用，且新生嬰兒已加入此團體計劃並成為被保險人時，保險人才會賠付上述新生嬰兒檢查的費用。 | ||
b) 對於產前期間因保障範圍內的醫療狀況所產生的實際住院治療費用或分娩期間因保障範圍內的醫療狀況所產生的實際住院治療費用，保險人僅將治療以下醫療狀況視為此福利保障b)中符合保障範圍內的醫療狀況。 | ||
－ 子宮外孕(胚胎在子宮以外的部位著床發育)； | ||
－ 葡萄胎(異常細胞在子宮內生長)； | ||
－ 胎盤滯留(胚胎滯留在子宮內)； | ||
－ 前置胎盤； | ||
－ 子癇(懷孕期間發生在先兆子癇之後的昏迷或抽搐)； | ||
－ 糖尿病(如果被保險人因自身與糖尿病有關的過往病史而有相應的責任免除，則被保險人不會因懷孕期間進行的任何糖尿病治療而獲得賠償)； | ||
－ 產後出♛(分娩後多個小時及多日大出♛)； | ||
－ 需要實時接受外科治療的流產。 | ||
本保障b)不包括自願/緊急剖腹產或“產程進展不良”的費用，除非是上述保障b)所列之符合保障範圍內的醫療狀況之一。 | ||
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。在第180日後至保單生效 一年期間產生的費用，此保障有95%的自付比例。不管投保人續保與否，被保險人必須完成180日 等待期才可賠付此保障。 | ||
因這是個人選擇，保險人對於育兒或其他相關課程一概不予賠付。 | ||
適用於10名或以上的團體保單。 | ||
責任免除6.27條款並不適用於此保障。 | ||
免賠額適用於此保障。 | ||
核保選項 | 易全保琥珀 |
37. 已聲明的既往病症的限額 | |
只適用於5-19名員工的統一投保的團體保險單。 此核保選項為已向保險人聲明並被保險人接受的既往病症提供有限的承保。 | 可供選項 |
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。 | 只適用於5-19名員工的統一投保的團體保險單 |
等待期結束後： 每個已聲明的既往病症的限額12,600人民幣 | |
等待期結束後和 團體計劃來年續保後：每個保險期內 每個已聲明的既往病症的限額25,200人民幣 | |
38. 既往病史不咎 適用於10名員工或以上的統一投保的團體保險單。 | 可供選項 |
免賠額選項 | 易全保琥珀 |
標準免賠額 | 3,150人民幣 |
自選免賠額 | 零 |
請注意：63,000人民幣或94,500人民幣免賠額僅適用於擁有不止一份健康保險單的投保人。如果 投保人購買本保險單作為二級醫療保險單，投保人只能選擇63,000人民幣或94,500人民幣免賠額選項。被保險人投保本保險時，需提供投保人主醫療保險的保險詳情。 | 950人民幣 1,570人民幣 6,300人民幣 |
15,700人民幣 | |
31,500人民幣 | |
63,000人民幣 | |
94,500人民幣 |
本保障一覽表僅供參考。詳情請參閱保險合同條款。
保障 | 易全保翡翠 |
年度最高保障限額 所有計劃均提供24/7熱線和援助服務 | 9,450,000人民幣 |
保障區域: | 全球保障 （不含美國） |
指定網絡: | 易全保綜合醫療網絡 |
1. 醫院收費、醫生和專科醫生費用 a) 醫院對住院或日間留院治療的患者收取的費用包括：床位費（一般病房/雙人病房或私人病房）；診斷檢測費用；手術室費用（含外科醫生與麻醉師收費）；合格護士護理的費用；由醫生或專科醫生開具的藥物和敷料的費用；手術期間醫生使用的手術器械費用；住院或日間留院期間手術前後的咨詢費；重症監護費用。 b) 輔助器材費用：屬於保障范圍內並因醫療所需，在住院或日間留院接受治療的6個月內，用於購買及租賃拐杖、支撐架、輔助行走器和自推式非ℝ子輪椅的費用。 | a) 全額賠償 上述保障需要預先獲得書面同意 🕿 b) 每個醫療狀況 最高限額9,450人民幣 |
2. 診斷程序 保險人應賠付由醫療必需而引致的實際醫療費用，包括：磁共振成象掃描(MRI)、正ℝ子放射斷層掃描(PET)和計算機斷層成像掃描(CT)的費用。 3. 腎衰竭和腎透析 a) 保險人應賠付被保險人住院接受腎衰竭(包括腎透析)治療時實際產生的醫療費用。 b) 保險人應賠付被保險人日間留院或在門診部接受腎衰竭(包括腎透析)治療時實際產生的醫療費用。 4. 器官移植 被保險人是器官受贈人時，有關腎臟、胰臟、肝臟、心臟、肺、骨髓、角膜的人體器官移植治療時產生的醫療費用。 當器官移植是由先天性疾病導致時，相關醫療費用應當依照本保險合同第五條項下第7款(先天性疾病)進行賠付，此時本保險合同第五條項下第4款(器官移植)對於相關費用一概不予賠付。 保險人僅賠付滿足以下條件的器官移植：在國際認可的醫院並由獲得認證的外科醫生執行器官移植；並根據WHO指南獲取的器官。 器官捐獻者和尋找器官捐獻者的相關醫療費用一概不予賠付。 5. 癌症治療 保險人應賠付因癌症而須住院﹑日間留院或門診治療時實際產生的醫療費用。此保障包括從診斷之時起，產生的腫瘤科醫生的費用﹑手術費用，放射療法和化學療法的單項或綜合費用。 | 住院、日間留院或門診全額賠償 磁共振成像掃描(MRI)、 正電子放射斷層掃描(PET)和計算機斷層成像掃描(CT)，需要預先獲得書面同意 🕿 a) 每個保險期內住院最高達6周全額賠償 b) 日間留院或門診治療每個保險期內 最高限額310,000人民幣 每個保險期內 最高限額945,000人民幣 全額賠償 |
保障 | 易全保翡翠 |
6. 新生嬰兒保障 | |
保險人應賠付被保險人的新生嬰兒因早產（即妊娠未滿37週分娩）或被保險人的新生嬰兒在出生 30日內出現急性的病症而需住院接受治療時而發生的實際醫療費用。 | |
此保障提供的前提是新生嬰兒在出生之日起30日內已經加入本保險合同並且投保人已支付保險費。 此保障經投保人和保險人雙方同意可適用於多胎分娩的情況。 如果保險人在嬰兒被加入保單之前需要詳細了解新生嬰兒的病史，則保險人保留其對所提供承保範圍應用特別限制條款的權利。 | 每個保險期內 最高限額220,500人民幣 |
請參閱第3條條款 － 新增新生嬰兒保單條款有關詳細信息。 | |
7. 先天性疾病 保險人應賠付被保險人因先天性疾病進行住院治療時實際產生的醫療費用。若新生嬰兒出生30日內因先天性疾病接受治療，將根據本保險合同第五條第6款 – 新生嬰兒保障規定提供此類病症的 保障，而本條款先天性疾病保障則不適用。最高保障限額應經投保人與保險人雙方同意，並在保險 合同中列明。 8. 家長住宿費用 保險人應賠付18周歲以下的被保險人因接受符合保障范圍內的住院治療時，其一位家長在醫院陪伴過夜而實際產生的住宿費用。 9. 新生嬰兒陪伴母親的醫院住宿費用 保險人應賠付新生嬰兒(出生16周及以下)在陪伴母親(母親為被保險人)接受住院治療符合保障范圍內的疾病時，醫院為新生嬰兒提供住宿而產生的實際費用。 10. 整形外科手術 保險人應賠付被保險人接受整形外科手術的實際醫療費用，此整形外科手術是為了恢復正常人體的功能或外貌，同時此整形外科手術是因被保險人在保險單生效日或批單簽發日(二者以後發生日為準)之後遭遇符合本保險合同保障範圍的意外事故或因接受符合本保險合同保障範圍內的疾病而接受了外科手術後產生。 11. 日間留院和門診手術 保險人應賠付被保險人在外科診所﹑醫院﹑日間護理中心或門診部進行的外科手術時實際產生的治療費用。 12. 緊急住院牙科治療 被保險人因遭遇意外事故后而必須住院一晚以上，其天然健全的牙齒因需進行緊急牙科修復治療，保險人應按實際發生的醫療費用賠付給被保險人。 該牙科治療必須在意外事故發生后的10日內進行。此保障包括因意外的外部撞擊造成的口腔傷害而須接受治療時產生的所有費用，但同時應滿足以下條件： a) 如果上述治療涉及更換齒冠、牙橋貼片、牙齒貼面或假牙，則保險人賠付合理慣常的費用，或賠付類似的或質量相當的更換費用； b) 如果臨床角度上需要植牙，那麼保險人賠付採用橋托產生的費用； c) 修復或重建在遭遇意外事故後損壞的假牙，但要求被保險人在遭遇意外事故時佩戴此類假牙。 13. 康復治療 專科醫生針對被保險人所患疾病進行治療時，推薦被保險人接受保險人認可的醫院康復中心接受 住院康復治療，保險人應賠付此種情況下實際產生的康復治療費用。但必須：被保險人連續三日 住院；專科醫生書面確認被保險人此時有必要接受康復治療。應在出院後14日內辦妥康復中心住院手續。上述治療應接受專科醫生的直接監管，並賠付如下費用： a) 專項治療病房的使用費； b) 物理治療費用； c) 語障治療費用； d) 職業病治療費用。 14. 家居護理 由醫生或專科醫生推薦，在被保險人接受住院或日間留院治療後，由合格護士在被保險人家中提供護理的費用。 此保障必須預先獲得保險人書面同意。 | 每個保險期內 最高限額220,500人民幣 |
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每個醫療狀況 最高達90日全額賠償 | |
每個醫療狀況 最高達30日全額賠償 | |
此保障需要預先獲得書面同意🕿 |
保障 | 易全保翡翠 |
15. 緊急救護運送費用 保險人應賠付陸上緊急救護交通運輸工具接送或在醫院之間轉送途中，或經醫生或專科醫生認為醫療必需的交通運輸工具實際產生的費用。 | 全額賠償 |
16. 轉運和送返 a) 轉運 保險人安排患有符合保障范圍內的危重被保險人運送到最近的醫療機構進行住院或日間留院治療。 賠付如下合理費用： i) 在被保險人須接受緊急治療而事故發生地無法提供醫療上必需的救護接送與護理的情況下，運送被保險人時產生的交通費用。其中包括一名隨行照料人員陪護行程中的經濟艙機票。 ii) 被保險人在接受日間留院治療期間，往返醫院赴診時的當地合理交通費用。 iii) 被保險人入院后隨行照料人員由於看望被保險人往返醫院時產生的合理交通費用。 iv) 僅限住院前或出院后短期內，被保險人接受專科醫生護理時的合理非醫院住宿費用。 在保險人認可的滑雪場或類似的冬季運動場所範圍之外，進行任何海空營救或山地救援時產生的轉運費用一概不予賠付。 保險人的醫學顧問將決定轉運時的最合適的交通方式。如違背保險人醫學顧問的意見，保險人 不賠付交通費用。另外，如果被保險人前往的醫院不具備合適醫療設施用以治療被保險人之符合保障范圍的醫療情況，則相關的交通費用將不予賠付。 b) 送返 經由醫療上必需且由保險人安排的轉運之後，在被保險人完成治療後的一個月內，在治療地的被保險人與被保險人的一位隨行照料人員將可獲安排經濟艙機票返回被保險人的國籍國或 居住國。 需要已經完成最初的醫療上必需的轉運，才可賠付此交通費用。 免賠額適用於此計劃保障。 17. 遺體運送 保險人應賠付被保險人因保障范圍內的醫療狀況導致死亡時產生以下合理和慣常的費用： a) 將被保險人遺體或骨灰運往其國籍國或居住國時的費用，或 b) 在被保險人死亡所在地，根據合理的慣例進行土葬或火葬時產生的費用。 18. 保障區域以外的緊急非選擇性治療 – 在不超過30日(含30日)的計劃行程 被保險人在保障區域以外若遇到意外事故或因某種突發性醫療狀況而形成對被保險人的健康構成威脅的突發危重疾病，而且其在上述緊急事件之後的24小時內接受醫生或專科醫生提供的治療，則保險人應賠付該期間實際產生的醫療費用。 19. 住院現金津貼 保險人應賠付被保險人在醫院接受住院治療期間每一晚的現金住院津貼，但應滿足以下條件： a) 被保險人在零時前於居住國家的公立醫院接受選擇性住院治療；或 b) 該計劃是二級醫療保險計劃。但是，如果被保險人的計劃免賠額是人民幣63,000或人民幣94,500，被保險人不可享用此保障。 該保障僅限於每個保險期間內累計最長不超過30晚(含30晚)。責任免除6.9條款並不適用於此保障。 | 綜合最高限額630,000人民幣 該保障需要預先獲得書面同意🕿 a) 轉運 i) 全額賠償 ii) 全額賠償 iii) 全額賠償 iv) 每日最高限額 1,200人民幣 每人每次轉運最高限額 47,000人民幣 該保障需要預先獲得書面同意🕿 b) 送返 全額賠償 該保障需要預先獲得書面同意🕿 a) 全額賠償 b) 最高限額63,000人民幣 意外：意外後的住院和日間留院治療全額賠償 疾病：住院和日間留院護理 每個保險期內 最高限額220,500人民幣 每晚最高限額1,575人民幣 |
保障 | 易全保翡翠 |
年度門診限額： 適用於保險合同第20款和21款，受年度最高保險計劃限額限制。 | 年度門診限額： 6,300人民幣 |
20. 門診醫生費用 a) 含括諮詢費在內的醫生收費，專科醫生費用，診斷檢查費用； b) 遠程醫療諮詢(醫生以ℝ子方式進行遠程醫療諮詢)； 如果被保險人在時康國際公佈的易全保綜合醫療網絡內列明的醫療服務提供方接受治療，符合保障範圍內的治療費用將全額賠付。 如果被保險人不是在時康國際公佈的易全保綜合醫療網絡內列明的醫療服務提供方接受治療，則只會賠付符合保障範圍內合理和慣常的醫療費用。 c) 處方藥和敷料的費用； d) 維生素和礦物質。 由醫生開具的維生素和礦物質。按照門診福利保障為維生素缺乏症確診者賠付由醫生開具的維生素。 任何手術前和出院後的門診費用將根據此保障進行賠付。 被保險人的保障範圍不包括被保險人因調理慢性疾病而承擔的費用。如果被保險人根據易全保翡翠計劃，易全保水晶計劃保險單選項投保則保險人將在本保險合同第五條項下第20款門診醫生費用承擔調理慢性疾病的治療費用。 請注意：如果索賠收據未顯示所提供醫療服務的明細，我們將僅支付不超過處方藥和敷料限額的符合條件的索賠。 年度門診限額：適用於保險合同第20款和21款，受年度最高保險計劃限額限制。 | a) 和 b) 全額賠償受年度 最高門診限額限制 c) 全額賠償受年度 最高門診限額限制 d) 每個保險期內 最高限額940人民幣 a), b), c), d) 受年度最高門診限額限制。 |
21. 門診物理治療和替代療法 保險人應賠付以下項目實際產生的醫療費用： a) 由獲得執業許可的物理治療師提供的物理治療費用。 b) 被保險人接受理療師的輔助藥物和治療，此類賠償可包括整骨療法﹑手足病治療和足病治療﹑整脊療法﹑順勢療法﹑飲食療法和針灸療法的費用。 c) 中醫執業醫師或阿育吠陀醫學執業醫師對被保險人進行門診治療時實際產生的醫療費用。 保險期內您可選擇此保障a)或b)，合計首5次治療不需轉介(飲食療法除外)，其他後續治療需醫生或專科醫生轉介。 年度門診限額：適用於保險合同第20款和21款，受年度最高保險計劃限額限制。 | a) 每次380人民幣 b) 每次380人民幣 c) 每次190人民幣 每個保險期內a), b), c) 綜合最高達10次， 受年度最高門診限額限制 |
保障 | 易全保翡翠 |
22. 更年期激素替代治療 需要進行激素替代治療以緩解更年期早發症狀之門診費用，但更年期發病和治療須始於40歲以下。 | 每個保險期內 最高限額1,200人民幣 |
23. 門診精神疾病治療 | |
由法定資質的心理學家及/或法定資質的精神病醫生的直接管理下，被保險人接受的門診治療。此項保障包括10次治療，賠付費用以本保障限額為準。 前5次就診無需醫生轉介，之後的就診則需要有醫生或專科醫生的轉介函和治療計劃。 | 每個保險期內最高10次，綜合最高限額1,850人民幣 |
24. 牙科 | |
保險人應賠付以下項目實際產生的醫療費用： | |
牙科治療：牙科執業醫生在牙科手術期間/牙科診所進行牙科治療的費用。牙科治療包括： | |
－ 牙齒檢查(若有必要其中包括照牙科X光)； | |
－ 預防性洗牙，拋光和窩溝封閉(每年一次)； | |
－ 補牙和拔牙(非手術和手術性)； | |
－ 根管治療 ； | 不予承保 |
－ 新裝或修復牙冠，假牙，嵌體和牙橋； | |
－ 進行牙根尖切除術。 | |
不包括種植牙和牙齒矯正治療保障。 | |
其他牙科治療一概不屬於此類保障。 | |
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。 | |
此保障有20%的自付比例。 | |
免賠額或門診每次就診免賠額並不適用於此保障。 |
附加選項 | 易全保翡翠 |
25. 中國大陸選擇 | |
保險人應賠付被保險人在中國大陸因住院﹑日間留院及接受門診治療時實際產生的符合保障范圍的醫療費用。標准的保險單保障限額適用於本條。 中國大陸以外的緊急非選擇性治療： | 可供選項 |
在最長期限為30日的計劃行程中，被保險人若在中國大陸以外的地區遇到意外事故或因某種突發性醫療狀況而引致對其健康構成即時威脅的嚴重疾病，在上述緊急事件之後的24小時內接受的醫生或專科醫生提供的治療。 因意外事故，需接受住院和日間留院治療，保險人應全額賠付。 | 中國大陸以外的緊急非選擇性治療， 因疾病治療的最高限額 150,000人民幣 |
因疾病需接受住院和日間留院治療，以投保人和保險人雙方同意的最高保障限額為限。最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。 | |
26. 病房限制(住宿最高限額800人民幣) 如本保險合同第五條項下第1款(a)項所述，被保險人在中國大陸住院時，每日最高限額800人民幣，從而在中國大陸醫院接受保障範圍內的住院或日間留院治療及任何醫生的治療。醫院的定義及範圍由保險人事先約定。 27. 昂貴醫院限制 保險人將事先指定某些提供住院﹑日間留院或門診治療服務的醫療機構為昂貴醫院。被保險人在中國大陸任何一家昂貴醫院接受承保范圍內的住院﹑日間留院或門診治療及任何醫學專家的 治療時，保險人將不會賠付實際產生的有關醫療費用。 28. 私人医院住院自付比例 對屬於保障範圍內在私人醫院的住院或日間留院治療時實際產生的醫療費用，被保險人需承擔 20%自付比例。 29. 年度最高保障限額1,000,000人民幣 在本保險合同的保險期間內，如果發生了本保險合同涵蓋的醫療事項，保險人應支付保險金額 不得超過相應的保障限額，且支付的總保險金金額不得超過本保險合同中規定的年度最高保障限額 1,000,000人民幣。 30. 門診費用的自付比例 保險人應賠付被保險人符合保障範圍內的門診治療實際產生的醫療費用，但門診治療有 20%的自付比例。 自付比例並不適用於以下項目：癌症治療﹑器官移植﹑腎衰竭和腎透析。但此項不適用於6,300人民幣免賠額或更高免賠額之計劃。 如果被保險人的保險單中含有生育保障﹑牙科保障或體檢﹑疫苗保障，其相應的自付額將會在被保險人的保障一覽表中列明。 31. 門診每次就診免賠額 被保險人接受屬於保障範圍的門診治療時，門診每次就診設有150人民幣免賠額。 門診每次就診免賠額適用於本保險合同第五條第20款(門診醫生費用)和21款(門診物理治療和替代療法) 。 但此項不適用於6,300人民幣免賠額或更高免賠額之計劃。 32. 取消藥物和敷料限額 通過選擇此選項，保障 20 c) 下的處方藥和敷料將全額賠償，但受年度最高門診限額限制。適用於3名員工或以上的統一投保的團體保險單。 | 可供選項 |
於中國大陸醫院 接受住院或日間留院治療每日最高限額800人民幣 | |
可供選項 | |
可供選項 | |
20%自付比例 | |
可供選項 | |
可供選項 | |
可供選項 | |
150人民幣 | |
不予承保 |
附加選項 | 易全保翡翠 |
33. 體檢和疫苗 – 選項1 適用於3名員工或以上的統一投保的團體保險單。 a) 體檢保障：保險人應賠付例行健康檢查，包括癌症篩查、乳腺癌1號和2號基因檢查(如直系家屬有病史)、骨密度檢查(50周歲以上女性被保險人每5年可做1次)、心♛管系統檢查，神經系統 檢查、生命體徵檢查(例如，♛壓、體重指數、尿分析和膽固醇)、兒童體檢(至5周歲)的費用 和/或 b) 疫苗保障：醫療必需的免疫疫苗和加強藥物注射，以及醫療必需的任何旅行疫苗和瘧疾預防注射，保險人將賠付相關藥物費用和咨詢費用。 責任免除6.9條款並不適用於此保障。 | 可供選項 a) 和 b) 每個保險期內的 綜合最高限額950人民幣 |
34. 體檢和疫苗 – 選項2 適用於3名員工或以上的統一投保的團體保險單。 a) 體檢保障：保險人應賠付例行健康檢查，包括癌症篩查、乳腺癌1號和2號基因檢查(如直系家屬有病史)、骨密度檢查(50周歲以上女性被保險人每5年可做1次)、心♛管系統檢查，神經系統 檢查、生命體徵檢查(例如，♛壓、體重指數、尿分析和膽固醇)、兒童體檢(至5周歲)的費用 和/或 b) 疫苗保障：醫療必需的免疫疫苗和加強藥物注射，以及醫療必需的任何旅行疫苗和瘧疾預防注射，保險人將賠付相關藥物費用和咨詢費用。 責任免除6.9條款並不適用於此保障。 35. 生育保障 – 選項1 a) 被保險人懷孕或分娩期間實際產生的醫療必需費用；包括分娩費用、產前與產後六週內檢查、掃描、自然分娩或自願/緊急剖腹產的費用。本保障亦包含出生24小時內兒科醫生就新生嬰兒 首次檢查/體檢的收費，以及幼兒1週歲生日前由醫生或專科醫生建議的兒科健康檢查費用，包括體格檢查，身高體重頭圍胸圍等測量，視力聽力等感知覺篩查，智能心理評估，生長發育檢查，遺傳病及代謝疾病篩查，疫苗注射，尿檢，結核試驗，♛球容積比，♛紅蛋白及其他♛液檢查，包括鐮狀細胞貧♛的篩查。 請注意此新生嬰兒檢查的費用保障，僅限於保險人已賠付本團體計劃下被保險人的分娩費用，且新生嬰兒已加入此團體計劃並成為被保險人時，保險人才會賠付上述新生嬰兒檢查的費用。 b) 對於產前期間因保障範圍內的醫療狀況所產生的實際住院治療費用或分娩期間因保障範圍內的醫療狀況所產生的實際住院治療費用，保險人僅將治療以下醫療狀況視為此福利保障b)中符合保障範圍內的醫療狀況。 － 子宮外孕(胚胎在子宮以外的部位著床發育)； － 葡萄胎(異常細胞在子宮內生長)； － 胎盤滯留(胚胎滯留在子宮內)； － 前置胎盤； － 子癇(懷孕期間發生在先兆子癇之後的昏迷或抽搐)； － 糖尿病(如果被保險人因自身與糖尿病有關的過往病史而有相應的責任免除，則被保險人不會因懷孕期間進行的任何糖尿病治療而獲得賠償)； － 產後出♛(分娩後多個小時及多日大出♛)； － 需要實時接受外科治療的流產。 本保障b)不包括自願/緊急剖腹產或“產程進展不良”的費用，除非是上述保障b)所列之符合保障範圍內的醫療狀況之一。 等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。在第180日後至保單生效 一年期間產生的費用，此保障有95%的自付比例。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。 因這是個人選擇，保險人對於育兒或其他相關課程一概不予賠付。適用於10名或以上的團體保單。 責任免除6.27條款並不適用於此保障。免賠額適用於此保障。 | 可供選項 a) 和 b) 每個保險期內的 綜合最高限額1,570人民幣 可供選項 適用於10名或以上的團體保單 a) 每個保險期內 最高限額31,500人民幣 b) 每個保險期內 最高限額75,600人民幣 |
附加選項 | 易全保翡翠 |
36. 生育保障 – 選項2 a) 被保險人懷孕或分娩期間實際產生的醫療必需費用；包括分娩費用、產前與產後六週內檢查、掃描、自然分娩或自願/緊急剖腹產的費用。本保障亦包含出生24小時內兒科醫生就新生嬰兒 首次檢查/體檢的收費，以及幼兒1週歲生日前由醫生或專科醫生建議的兒科健康檢查費用，包括體格檢查，身高體重頭圍胸圍等測量，視力聽力等感知覺篩查，智能心理評估，生長發育檢查，遺傳病及代謝疾病篩查，疫苗注射，尿檢，結核試驗，♛球容積比，♛紅蛋白及其他♛液檢查，包括鐮狀細胞貧♛的篩查。 請注意此新生嬰兒檢查的費用保障，僅限於保險人已賠付本團體計劃下被保險人的分娩費用，且新生嬰兒已加入此團體計劃並成為被保險人時，保險人才會賠付上述新生嬰兒檢查的費用。 b) 對於產前期間因保障範圍內的醫療狀況所產生的實際住院治療費用或分娩期間因保障範圍內的醫療狀況所產生的實際住院治療費用，保險人僅將治療以下醫療狀況視為此福利保障b)中符合保障範圍內的醫療狀況。 － 子宮外孕(胚胎在子宮以外的部位著床發育)； － 葡萄胎(異常細胞在子宮內生長)； － 胎盤滯留(胚胎滯留在子宮內)； － 前置胎盤； － 子癇(懷孕期間發生在先兆子癇之後的昏迷或抽搐)； － 糖尿病(如果被保險人因自身與糖尿病有關的過往病史而有相應的責任免除，則被保險人不會因懷孕期間進行的任何糖尿病治療而獲得賠償)； － 產後出♛(分娩後多個小時及多日大出♛)； － 需要實時接受外科治療的流產。 本保障b)不包括自願/緊急剖腹產或“產程進展不良”的費用，除非是上述保障b)所列之符合保障範圍內的醫療狀況之一。 等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。在第180日後至保單生效 一年期間產生的費用，此保障有95%的自付比例。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。 因這是個人選擇，保險人對於育兒或其他相關課程一概不予賠付。適用於10名或以上的團體保單。 責任免除6.27條款並不適用於此保障。免賠額適用於此保障。 | 可供選項 適用於10名或以上的團體保單 a) 每個保險期內 最高限額44,100人民幣 b) 每個保險期內 最高限額94,500人民幣 |
核保選項 | 易全保翡翠 |
37. 已聲明的既往病症的限額 | |
只適用於5-19名員工的統一投保的團體保險單。 此核保選項為已向保險人聲明並被保險人接受的既往病症提供有限的承保。 | 可供選項 |
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。 | 只適用於5-19名員工的統一投保的團體保險單 |
等待期結束後： 每個已聲明的既往病症的限額12,600人民幣 | |
等待期結束後和 團體計劃來年續保後：每個保險期內 每個已聲明的既往病症的限額25,200人民幣 | |
38. 既往病史不咎 適用於10名員工或以上的統一投保的團體保險單。 | 可供選項 |
免賠額選項 | 易全保翡翠 |
標準免賠額 | 3,150人民幣 |
自選免賠額 | 零 |
請注意：63,000人民幣或94,500人民幣免賠額僅適用於擁有不止一份健康保險單的投保人。如果 投保人購買本保險單作為二級醫療保險單，投保人只能選擇63,000人民幣或94,500人民幣免賠額選項。被保險人投保本保險時，需提供投保人主醫療保險的保險詳情。 | 950人民幣 1,570人民幣 6,300人民幣 |
15,700人民幣 | |
31,500人民幣 | |
63,000人民幣 | |
94,500人民幣 |
本保障一覽表僅供參考。詳情請參閱保險合同條款。
保障 | 易全保水晶 |
年度最高保障限額 所有計劃均提供24/7熱線和援助服務 | 9,450,000人民幣 |
保障區域: | 全球保障 （不含美國） |
指定網絡: | 易全保綜合醫療網絡 |
1. 醫院收費、醫生和專科醫生費用 a) 醫院對住院或日間留院治療的患者收取的費用包括：床位費（一般病房/雙人病房或私人病房）；診斷檢測費用；手術室費用（含外科醫生與麻醉師收費）；合格護士護理的費用；由醫生或專科醫生開具的藥物和敷料的費用；手術期間醫生使用的手術器械費用；住院或日間留院期間手術前後的咨詢費；重症監護費用。 b) 輔助器材費用：屬於保障范圍內並因醫療所需，在住院或日間留院接受治療的6個月內，用於購買及租賃拐杖、支撐架、輔助行走器和自推式非ℝ子輪椅的費用。 | a) 全額賠償 上述保障需要預先獲得書面同意 🕿 b) 每個醫療狀況 最高限額9,450人民幣 |
2. 診斷程序 保險人應賠付由醫療必需而引致的實際醫療費用，包括：磁共振成象掃描(MRI)、正ℝ子放射斷層掃描(PET)和計算機斷層成像掃描(CT)的費用。 3. 腎衰竭和腎透析 a) 保險人應賠付被保險人住院接受腎衰竭(包括腎透析)治療時實際產生的醫療費用。 b) 保險人應賠付被保險人日間留院或在門診部接受腎衰竭(包括腎透析)治療時實際產生的醫療費用。 4. 器官移植 被保險人是器官受贈人時，有關腎臟、胰臟、肝臟、心臟、肺、骨髓、角膜的人體器官移植治療時產生的醫療費用。 當器官移植是由先天性疾病導致時，相關醫療費用應當依照本保險合同第五條項下第7款(先天性疾病)進行賠付，此時本保險合同第五條項下第4款(器官移植)對於相關費用一概不予賠付。 保險人僅賠付滿足以下條件的器官移植：在國際認可的醫院並由獲得認證的外科醫生執行器官移植；並根據WHO指南獲取的器官。 器官捐獻者和尋找器官捐獻者的相關醫療費用一概不予賠付。 5. 癌症治療 保險人應賠付因癌症而須住院﹑日間留院或門診治療時實際產生的醫療費用。此保障包括從診斷之時起，產生的腫瘤科醫生的費用﹑手術費用，放射療法和化學療法的單項或綜合費用。 | 住院、日間留院或門診全額賠償 磁共振成像掃描(MRI)、 正電子放射斷層掃描(PET)和計算機斷層成像掃描(CT)，需要預先獲得書面同意 🕿 a) 每個保險期內住院最高達6周全額賠償 b) 日間留院或門診治療每個保險期內 最高限額310,000人民幣 每個保險期內 最高限額945,000人民幣 全額賠償 |
保障 | 易全保水晶 |
6. 新生嬰兒保障 | |
保險人應賠付被保險人的新生嬰兒因早產（即妊娠未滿37週分娩）或被保險人的新生嬰兒在出生 30日內出現急性的病症而需住院接受治療時而發生的實際醫療費用。 | |
此保障提供的前提是新生嬰兒在出生之日起30日內已經加入本保險合同並且投保人已支付保險費。 此保障經投保人和保險人雙方同意可適用於多胎分娩的情況。 如果保險人在嬰兒被加入保單之前需要詳細了解新生嬰兒的病史，則保險人保留其對所提供承保範圍應用特別限制條款的權利。 | 每個保險期內 最高限額220,500人民幣 |
請參閱第3條條款 － 新增新生嬰兒保單條款有關詳細信息。 | |
7. 先天性疾病 保險人應賠付被保險人因先天性疾病進行住院治療時實際產生的醫療費用。若新生嬰兒出生30日內因先天性疾病接受治療，將根據本保險合同第五條第6款 – 新生嬰兒保障規定提供此類病症的 保障，而本條款先天性疾病保障則不適用。最高保障限額應經投保人與保險人雙方同意，並在保險 合同中列明。 8. 家長住宿費用 保險人應賠付18周歲以下的被保險人因接受符合保障范圍內的住院治療時，其一位家長在醫院陪伴過夜而實際產生的住宿費用。 9. 新生嬰兒陪伴母親的醫院住宿費用 保險人應賠付新生嬰兒(出生16周及以下)在陪伴母親(母親為被保險人)接受住院治療符合保障范圍內的疾病時，醫院為新生嬰兒提供住宿而產生的實際費用。 10. 整形外科手術 保險人應賠付被保險人接受整形外科手術的實際醫療費用，此整形外科手術是為了恢復正常人體的功能或外貌，同時此整形外科手術是因被保險人在保險單生效日或批單簽發日(二者以後發生日為準)之後遭遇符合本保險合同保障範圍的意外事故或因接受符合本保險合同保障範圍內的疾病而接受了外科手術後產生。 11. 日間留院和門診手術 保險人應賠付被保險人在外科診所﹑醫院﹑日間護理中心或門診部進行的外科手術時實際產生的治療費用。 12. 緊急住院牙科治療 被保險人因遭遇意外事故后而必須住院一晚以上，其天然健全的牙齒因需進行緊急牙科修復治療，保險人應按實際發生的醫療費用賠付給被保險人。 該牙科治療必須在意外事故發生后的10日內進行。此保障包括因意外的外部撞擊造成的口腔傷害而須接受治療時產生的所有費用，但同時應滿足以下條件： a) 如果上述治療涉及更換齒冠、牙橋貼片、牙齒貼面或假牙，則保險人賠付合理慣常的費用，或賠付類似的或質量相當的更換費用； b) 如果臨床角度上需要植牙，那麼保險人賠付採用橋托產生的費用； c) 修復或重建在遭遇意外事故後損壞的假牙，但要求被保險人在遭遇意外事故時佩戴此類假牙。 13. 康復治療 專科醫生針對被保險人所患疾病進行治療時，推薦被保險人接受保險人認可的醫院康復中心接受 住院康復治療，保險人應賠付此種情況下實際產生的康復治療費用。但必須：被保險人連續三日 住院；專科醫生書面確認被保險人此時有必要接受康復治療。應在出院後14日內辦妥康復中心住院手續。上述治療應接受專科醫生的直接監管，並賠付如下費用： a) 專項治療病房的使用費； b) 物理治療費用； c) 語障治療費用； d) 職業病治療費用。 14. 家居護理 由醫生或專科醫生推薦，在被保險人接受住院或日間留院治療後，由合格護士在被保險人家中提供護理的費用。 此保障必須預先獲得保險人書面同意。 | 每個保險期內 最高限額220,500人民幣 |
全額賠償 | |
全額賠償 | |
全額賠償 | |
全額賠償 | |
全額賠償 | |
每個醫療狀況 最高達90日全額賠償 | |
每個醫療狀況 最高達30日全額賠償 | |
此保障需要預先獲得書面同意🕿 |
保障 | 易全保水晶 |
15. 緊急救護運送費用 保險人應賠付陸上緊急救護交通運輸工具接送或在醫院之間轉送途中，或經醫生或專科醫生認為醫療必需的交通運輸工具實際產生的費用。 | 全額賠償 |
16. 轉運和送返 a) 轉運 保險人安排患有符合保障范圍內的危重被保險人運送到最近的醫療機構進行住院或日間留院治療。 賠付如下合理費用： i) 在被保險人須接受緊急治療而事故發生地無法提供醫療上必需的救護接送與護理的情況下，運送被保險人時產生的交通費用。其中包括一名隨行照料人員陪護行程中的經濟艙機票。 ii) 被保險人在接受日間留院治療期間，往返醫院赴診時的當地合理交通費用。 iii) 被保險人入院后隨行照料人員由於看望被保險人往返醫院時產生的合理交通費用。 iv) 僅限住院前或出院后短期內，被保險人接受專科醫生護理時的合理非醫院住宿費用。 在保險人認可的滑雪場或類似的冬季運動場所範圍之外，進行任何海空營救或山地救援時產生的轉運費用一概不予賠付。 保險人的醫學顧問將決定轉運時的最合適的交通方式。如違背保險人醫學顧問的意見，保險人 不賠付交通費用。另外，如果被保險人前往的醫院不具備合適醫療設施用以治療被保險人之符合保障范圍的醫療情況，則相關的交通費用將不予賠付。 b) 送返 經由醫療上必需且由保險人安排的轉運之後，在被保險人完成治療後的一個月內，在治療地的被保險人與被保險人的一位隨行照料人員將可獲安排經濟艙機票返回被保險人的國籍國或 居住國。 需要已經完成最初的醫療上必需的轉運，才可賠付此交通費用。 免賠額適用於此計劃保障。 17. 遺體運送 保險人應賠付被保險人因保障范圍內的醫療狀況導致死亡時產生以下合理和慣常的費用： a) 將被保險人遺體或骨灰運往其國籍國或居住國時的費用，或 b) 在被保險人死亡所在地，根據合理的慣例進行土葬或火葬時產生的費用。 18. 保障區域以外的緊急非選擇性治療 – 在不超過30日(含30日)的計劃行程 被保險人在保障區域以外若遇到意外事故或因某種突發性醫療狀況而形成對被保險人的健康構成威脅的突發危重疾病，而且其在上述緊急事件之後的24小時內接受醫生或專科醫生提供的治療，則保險人應賠付該期間實際產生的醫療費用。 19. 住院現金津貼 保險人應賠付被保險人在醫院接受住院治療期間每一晚的現金住院津貼，但應滿足以下條件： a) 被保險人在零時前於居住國家的公立醫院接受選擇性住院治療；或 b) 該計劃是二級醫療保險計劃。但是，如果被保險人的計劃免賠額是人民幣63,000或人民幣94,500，被保險人不可享用此保障。 該保障僅限於每個保險期間內累計最長不超過30晚(含30晚)。責任免除6.9條款並不適用於此保障。 | 綜合最高限額630,000人民幣 該保障需要預先獲得書面同意🕿 a) 轉運 i) 全額賠償 ii) 全額賠償 iii) 全額賠償 iv) 每日最高限額 1,200人民幣 每人每次轉運最高限額 47,000人民幣 該保障需要預先獲得書面同意🕿 b) 送返 全額賠償 該保障需要預先獲得書面同意🕿 a) 全額賠償 b) 最高限額63,000人民幣 意外：意外後的住院和日間留院治療全額賠償 疾病：住院和日間留院護理 每個保險期內 最高限額220,500人民幣 每晚最高限額1,575人民幣 |
保障 | 易全保水晶 |
年度門診限額： 適用於保險合同第20款和21款，受年度最高保險計劃限額限制。 | 年度門診限額： 15,750人民幣 |
20. 門診醫生費用 a) 含括諮詢費在內的醫生收費，專科醫生費用，診斷檢查費用； b) 遠程醫療諮詢(醫生以ℝ子方式進行遠程醫療諮詢)； 如果被保險人在時康國際公佈的易全保綜合醫療網絡內列明的醫療服務提供方接受治療，符合保障範圍內的治療費用將全額賠付。 如果被保險人不是在時康國際公佈的易全保綜合醫療網絡內列明的醫療服務提供方接受治療，則只會賠付符合保障範圍內合理和慣常的醫療費用。 c) 處方藥和敷料的費用； d) 維生素和礦物質。 由醫生開具的維生素和礦物質。按照門診福利保障為維生素缺乏症確診者賠付由醫生開具的維生素。 任何手術前和出院後的門診費用將根據此保障進行賠付。 被保險人的保障範圍不包括被保險人因調理慢性疾病而承擔的費用。如果被保險人根據易全保翡翠計劃，易全保水晶計劃保險單選項投保則保險人將在本保險合同第五條項下第20款門診醫生費用承擔調理慢性疾病的治療費用。 請注意：如果索賠收據未顯示所提供醫療服務的明細，我們將僅支付不超過處方藥和敷料限額的符合條件的索賠。 年度門診限額：適用於保險合同第20款和21款，受年度最高保險計劃限額限制。 | a) 和 b) 全額賠償受年度 最高門診限額限制 c) 每個保險期內 最高限額7,875人民幣 d) 每個保險期內 最高限額940人民幣 a), b), c), d) 受年度最高門診限額限制。 |
21. 門診物理治療和替代療法 保險人應賠付以下項目實際產生的醫療費用： a) 由獲得執業許可的物理治療師提供的物理治療費用。 b) 被保險人接受理療師的輔助藥物和治療，此類賠償可包括整骨療法﹑手足病治療和足病治療﹑整脊療法﹑順勢療法﹑飲食療法和針灸療法的費用。 c) 中醫執業醫師或阿育吠陀醫學執業醫師對被保險人進行門診治療時實際產生的醫療費用。 保險期內您可選擇此保障a)或b)，合計首5次治療不需轉介(飲食療法除外)，其他後續治療需醫生或專科醫生轉介。 年度門診限額：適用於保險合同第20款和21款，受年度最高保險計劃限額限制。 | a) 每次500人民幣 b) 每次500人民幣 c) 每次250人民幣 每個保險期內a), b), c) 綜合最高達10次， 受年度最高門診限額限制 |
保障 | 易全保水晶 |
22. 更年期激素替代治療 需要進行激素替代治療以緩解更年期早發症狀之門診費用，但更年期發病和治療須始於40歲以下。 | 每個保險期內 最高限額1,850人民幣 |
23. 門診精神疾病治療 | |
由法定資質的心理學家及/或法定資質的精神病醫生的直接管理下，被保險人接受的門診治療。此項保障包括10次治療，賠付費用以本保障限額為準。 前5次就診無需醫生轉介，之後的就診則需要有醫生或專科醫生的轉介函和治療計劃。 | 每個保險期內最高10次，綜合最高限額2,500人民幣 |
24. 牙科 | |
保險人應賠付以下項目實際產生的醫療費用： | |
牙科治療：牙科執業醫生在牙科手術期間/牙科診所進行牙科治療的費用。牙科治療包括： | |
－ 牙齒檢查(若有必要其中包括照牙科X光)； | |
－ 預防性洗牙，拋光和窩溝封閉(每年一次)； | |
－ 補牙和拔牙(非手術和手術性)； | |
－ 根管治療 ； － 新裝或修復牙冠，假牙，嵌體和牙橋； | 每個保險期內 最高限額1,900人民幣 |
－ 進行牙根尖切除術。 | |
不包括種植牙和牙齒矯正治療保障。 | |
其他牙科治療一概不屬於此類保障。 | |
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。 | |
此保障有20%的自付比例。 | |
免賠額或門診每次就診免賠額並不適用於此保障。 |
附加選項 | 易全保水晶 |
25. 中國大陸選擇 | |
保險人應賠付被保險人在中國大陸因住院﹑日間留院及接受門診治療時實際產生的符合保障范圍的醫療費用。標准的保險單保障限額適用於本條。 中國大陸以外的緊急非選擇性治療： | 可供選項 |
在最長期限為30日的計劃行程中，被保險人若在中國大陸以外的地區遇到意外事故或因某種突發性醫療狀況而引致對其健康構成即時威脅的嚴重疾病，在上述緊急事件之後的24小時內接受的醫生或專科醫生提供的治療。 因意外事故，需接受住院和日間留院治療，保險人應全額賠付。 | 中國大陸以外的緊急非選擇性治療， 因疾病治療的最高限額 150,000人民幣 |
因疾病需接受住院和日間留院治療，以投保人和保險人雙方同意的最高保障限額為限。最高保障限額應經投保人與保險人雙方同意，並在保險合同中列明。 | |
26. 病房限制(住宿最高限額800人民幣) 如本保險合同第五條項下第1款(a)項所述，被保險人在中國大陸住院時，每日最高限額800人民幣，從而在中國大陸醫院接受保障範圍內的住院或日間留院治療及任何醫生的治療。醫院的定義及範圍由保險人事先約定。 27. 昂貴醫院限制 保險人將事先指定某些提供住院﹑日間留院或門診治療服務的醫療機構為昂貴醫院。被保險人在中國大陸任何一家昂貴醫院接受承保范圍內的住院﹑日間留院或門診治療及任何醫學專家的 治療時，保險人將不會賠付實際產生的有關醫療費用。 28. 私人医院住院自付比例 對屬於保障範圍內在私人醫院的住院或日間留院治療時實際產生的醫療費用，被保險人需承擔 20%自付比例。 29. 年度最高保障限額1,000,000人民幣 在本保險合同的保險期間內，如果發生了本保險合同涵蓋的醫療事項，保險人應支付保險金額 不得超過相應的保障限額，且支付的總保險金金額不得超過本保險合同中規定的年度最高保障限額 1,000,000人民幣。 30. 門診費用的自付比例 保險人應賠付被保險人符合保障範圍內的門診治療實際產生的醫療費用，但門診治療有 20%的自付比例。 自付比例並不適用於以下項目：癌症治療﹑器官移植﹑腎衰竭和腎透析。但此項不適用於6,300人民幣免賠額或更高免賠額之計劃。 如果被保險人的保險單中含有生育保障﹑牙科保障或體檢﹑疫苗保障，其相應的自付額將會在被保險人的保障一覽表中列明。 31. 門診每次就診免賠額 被保險人接受屬於保障範圍的門診治療時，門診每次就診設有150人民幣免賠額。 門診每次就診免賠額適用於本保險合同第五條第20款(門診醫生費用)和21款(門診物理治療和替代療法) 。 但此項不適用於6,300人民幣免賠額或更高免賠額之計劃。 32. 取消藥物和敷料限額 通過選擇此選項，保障 20 c) 下的處方藥和敷料將全額賠償，但受年度最高門診限額限制。適用於3名員工或以上的統一投保的團體保險單。 | 可供選項 |
於中國大陸醫院 接受住院或日間留院治療每日最高限額800人民幣 | |
可供選項 | |
可供選項 | |
20%自付比例 | |
可供選項 | |
可供選項 | |
可供選項 | |
150人民幣 | |
可供選項 | |
適用於3名員工或以上的統一投保的團體保險單 |
附加選項 | 易全保水晶 |
33. 體檢和疫苗 – 選項1 適用於3名員工或以上的統一投保的團體保險單。 a) 體檢保障：保險人應賠付例行健康檢查，包括癌症篩查、乳腺癌1號和2號基因檢查(如直系家屬有病史)、骨密度檢查(50周歲以上女性被保險人每5年可做1次)、心♛管系統檢查，神經系統 檢查、生命體徵檢查(例如，♛壓、體重指數、尿分析和膽固醇)、兒童體檢(至5周歲)的費用 和/或 b) 疫苗保障：醫療必需的免疫疫苗和加強藥物注射，以及醫療必需的任何旅行疫苗和瘧疾預防注射，保險人將賠付相關藥物費用和咨詢費用。 責任免除6.9條款並不適用於此保障。 | 可供選項 a) 和 b) 每個保險期內的 綜合最高限額950人民幣 |
34. 體檢和疫苗 – 選項2 適用於3名員工或以上的統一投保的團體保險單。 a) 體檢保障：保險人應賠付例行健康檢查，包括癌症篩查、乳腺癌1號和2號基因檢查(如直系家屬有病史)、骨密度檢查(50周歲以上女性被保險人每5年可做1次)、心♛管系統檢查，神經系統 檢查、生命體徵檢查(例如，♛壓、體重指數、尿分析和膽固醇)、兒童體檢(至5周歲)的費用 和/或 b) 疫苗保障：醫療必需的免疫疫苗和加強藥物注射，以及醫療必需的任何旅行疫苗和瘧疾預防注射，保險人將賠付相關藥物費用和咨詢費用。 責任免除6.9條款並不適用於此保障。 35. 生育保障 – 選項1 a) 被保險人懷孕或分娩期間實際產生的醫療必需費用；包括分娩費用、產前與產後六週內檢查、掃描、自然分娩或自願/緊急剖腹產的費用。本保障亦包含出生24小時內兒科醫生就新生嬰兒 首次檢查/體檢的收費，以及幼兒1週歲生日前由醫生或專科醫生建議的兒科健康檢查費用，包括體格檢查，身高體重頭圍胸圍等測量，視力聽力等感知覺篩查，智能心理評估，生長發育檢查，遺傳病及代謝疾病篩查，疫苗注射，尿檢，結核試驗，♛球容積比，♛紅蛋白及其他♛液檢查，包括鐮狀細胞貧♛的篩查。 請注意此新生嬰兒檢查的費用保障，僅限於保險人已賠付本團體計劃下被保險人的分娩費用，且新生嬰兒已加入此團體計劃並成為被保險人時，保險人才會賠付上述新生嬰兒檢查的費用。 b) 對於產前期間因保障範圍內的醫療狀況所產生的實際住院治療費用或分娩期間因保障範圍內的醫療狀況所產生的實際住院治療費用，保險人僅將治療以下醫療狀況視為此福利保障b)中符合保障範圍內的醫療狀況。 － 子宮外孕(胚胎在子宮以外的部位著床發育)； － 葡萄胎(異常細胞在子宮內生長)； － 胎盤滯留(胚胎滯留在子宮內)； － 前置胎盤； － 子癇(懷孕期間發生在先兆子癇之後的昏迷或抽搐)； － 糖尿病(如果被保險人因自身與糖尿病有關的過往病史而有相應的責任免除，則被保險人不會因懷孕期間進行的任何糖尿病治療而獲得賠償)； － 產後出♛(分娩後多個小時及多日大出♛)； － 需要實時接受外科治療的流產。 本保障b)不包括自願/緊急剖腹產或“產程進展不良”的費用，除非是上述保障b)所列之符合保障範圍內的醫療狀況之一。 等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。在第180日後至保單生效 一年期間產生的費用，此保障有95%的自付比例。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。 因這是個人選擇，保險人對於育兒或其他相關課程一概不予賠付。適用於10名或以上的團體保單。 責任免除6.27條款並不適用於此保障。免賠額適用於此保障。 | 可供選項 a) 和 b) 每個保險期內的 綜合最高限額1,570人民幣 可供選項 適用於10名或以上的團體保單 a) 每個保險期內 最高限額31,500人民幣 b) 每個保險期內 最高限額75,600人民幣 |
附加選項 | 易全保水晶 |
36. 生育保障 – 選項2 a) 被保險人懷孕或分娩期間實際產生的醫療必需費用；包括分娩費用、產前與產後六週內檢查、掃描、自然分娩或自願/緊急剖腹產的費用。本保障亦包含出生24小時內兒科醫生就新生嬰兒 首次檢查/體檢的收費，以及幼兒1週歲生日前由醫生或專科醫生建議的兒科健康檢查費用，包括體格檢查，身高體重頭圍胸圍等測量，視力聽力等感知覺篩查，智能心理評估，生長發育檢查，遺傳病及代謝疾病篩查，疫苗注射，尿檢，結核試驗，♛球容積比，♛紅蛋白及其他♛液檢查，包括鐮狀細胞貧♛的篩查。 請注意此新生嬰兒檢查的費用保障，僅限於保險人已賠付本團體計劃下被保險人的分娩費用，且新生嬰兒已加入此團體計劃並成為被保險人時，保險人才會賠付上述新生嬰兒檢查的費用。 b) 對於產前期間因保障範圍內的醫療狀況所產生的實際住院治療費用或分娩期間因保障範圍內的醫療狀況所產生的實際住院治療費用，保險人僅將治療以下醫療狀況視為此福利保障b)中符合保障範圍內的醫療狀況。 － 子宮外孕(胚胎在子宮以外的部位著床發育)； － 葡萄胎(異常細胞在子宮內生長)； － 胎盤滯留(胚胎滯留在子宮內)； － 前置胎盤； － 子癇(懷孕期間發生在先兆子癇之後的昏迷或抽搐)； － 糖尿病(如果被保險人因自身與糖尿病有關的過往病史而有相應的責任免除，則被保險人不會因懷孕期間進行的任何糖尿病治療而獲得賠償)； － 產後出♛(分娩後多個小時及多日大出♛)； － 需要實時接受外科治療的流產。 本保障b)不包括自願/緊急剖腹產或“產程進展不良”的費用，除非是上述保障b)所列之符合保障範圍內的醫療狀況之一。 等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。在第180日後至保單生效 一年期間產生的費用，此保障有95%的自付比例。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。 因這是個人選擇，保險人對於育兒或其他相關課程一概不予賠付。適用於10名或以上的團體保單。 責任免除6.27條款並不適用於此保障。免賠額適用於此保障。 | 可供選項 適用於10名或以上的團體保單 a) 每個保險期內 最高限額44,100人民幣 b) 每個保險期內 最高限額94,500人民幣 |
核保選項 | 易全保水晶 |
37. 已聲明的既往病症的限額 | |
只適用於5-19名員工的統一投保的團體保險單。 此核保選項為已向保險人聲明並被保險人接受的既往病症提供有限的承保。 | 可供選項 |
等待期：被保險人保單生效日後的180日內產生的任何費用不予賠付。不管投保人續保與否，被保險人必須完成180日等待期才可賠付此保障。 | 只適用於5-19名員工的統一投保的團體保險單 |
等待期結束後： 每個已聲明的既往病症的限額12,600人民幣 | |
等待期結束後和 團體計劃來年續保後：每個保險期內 每個已聲明的既往病症的限額25,200人民幣 | |
38. 既往病史不咎 適用於10名員工或以上的統一投保的團體保險單。 | 可供選項 |
免賠額選項 | 易全保水晶 |
標準免賠額 | 3,150人民幣 |
自選免賠額 | 零 |
請注意：63,000人民幣或94,500人民幣免賠額僅適用於擁有不止一份健康保險單的投保人。如果 投保人購買本保險單作為二級醫療保險單，投保人只能選擇63,000人民幣或94,500人民幣免賠額選項。被保險人投保本保險時，需提供投保人主醫療保險的保險詳情。 | 950人民幣 1,570人民幣 6,300人民幣 |
15,700人民幣 | |
31,500人民幣 | |
63,000人民幣 | |
94,500人民幣 |
Now Health International
阿联酋 UAE
Arabia Insurance Company S.A.L.
c/o Now Health International Gulf Third Party Administrators LLC, Unit 3701, Burj Al Salam Building, 3 Sheikh Zayed Rd,
PO Box 334337, Dubai, United Arab Emirates
T +971 (0) 4450 1410 | F +971 (0) 4450 1416
全球 Rest of the World
Now Health International Limited PO Box 482055, Dubai, UAE
T +971 (0) 4450 1510 | F +971 (0) 4450 1530
CustomerService@now-health.com
保險合同由亞太財產保險有限公司簽發，並委託時康管理顧問(上海)有限公司進行保單管理。亞太財產保險有限公司地址：中國深圳市福田區中心區
福華一路免稅商務大廈29-30樓，郵編：518048
時康管理顧問(上海)有限公司地址：中國上海市虹口區吳淞路218號寶礦國際大廈11樓1103B室-1105室，郵編：200080
Policies are issued by Asia-Pacific Property & Casualty Insurance Co., Ltd. Registered Office: 29-30F., Dutyfree Business Building, 1st Fuhua Road, Futian CBD, Shenzhen 518048, China.
Policies are administered by Now Health International (Shanghai) Limited. Room 1103B–1105, 11/F, BM Tower, No. 218 Wusong Road, Hongkou District, Shanghai 200080, China.
歐洲 (馬耳他) Europe (Malta) Now Health International Services (Europe) Limited Dragonara Business Centre 5th Floor,
Dragonara Road, St Julian’s, STJ 3141, Malta
T +356 2260 5110
CustomerService@now-health.com
歐洲 (西班牙) Europe (Spain) Now Health International Services (Europe) Limited Edificio Orense 34 (Torre Norte – Planta 07),
Calle Orense 34, CP 28020 - Madrid, Spain
T +34 911 841 690
CustomerService@now-health.com
英國 United Kingdom
Now Health International (UK) Limited Suite 2.3, Building Three, Watchmoor Park, Camberley,
Surrey, GU15 3YL, United Kingdom T +44 (0) 1276 602110 | F +44 (0) 1276 602130
CustomerService@now-health.com
亞太 Asia Pacific Now Health International (Asia Pacific) Limited Units 1501-3, 15/F, AIA Tower, 183 Electric Road
North Point, Hong Kong T +852 2279 7310 | F +852 2279 7330
CustomerService@now-health.com
中國 China Asia-Pacific Property & Casualty Insurance Co., Ltd. c/o Now Health International (Shanghai) Limited Room 1103B–1105, 11/F, BM Tower
No. 218 Wusong Road Hongkou District, Shanghai 200080, China
T +(86) 400 077 7500 / +86 21 6156 0910 | F +(86) 400 077 7900
CustomerService@now-health.com
新加坡 Singapore
Now Health International (Singapore) Pte. Ltd.
4 Robinson Road #07-01A/02 The House of Eden
Singapore 048543
T +65 6880 2300 | F +65 6220 6950
CustomerService@now-health.com
印尼 Indonesia PT Now Health International Indonesia 17/F, Indonesia Stock Exchange, Tower II Jl. Jend. Sudirman Kav. 52 – 53
Jakarta 12190, Indonesia
Toll-free 0800 1 889900/ Toll +62 21 2783 6910 | F +62 21 515 7639
CustomerService@now-health.com
SC CH 29002 02/04/2024
SimpleCare Policy Wording
Companies (April 2024)
Contents
A. Policy Wording
1 General 03
2 Insurance Liability 04
3 Exclusions 13
4 Insurance Sum Assured and Insurance Premium 18
5 Coverage Period 18
6 Insurer’s Obligations 19
7 Policyholder, Insured Person and Beneficiary’s Obligations 20
8 Claim and Payment of Insurance Compensation 21
9 Dispute Resolution and Applicable Law 22
10 Miscellaneous 23
11 General Conditions 25
12 Definitions 26
B. Benefit Schedule 31
SimpleCare Policy Wording (April 2024) | General | 03
A. Policy Wording
1. General
Asia-Pacific Property & Casualty Insurance Co., Ltd.
Companies SimpleCare Medical Insurance (April 2024) Policy Wording (Registration No: C00003832512024032959041)
Article 1
This insurance contract consists of the policy wording, group application form, insurance policy or certificate, benefit schedule and endorsement. Any other agreement related to this insurance contract shall be in written form and agreed by insurer.
Article 2
The policyholder is the group applying for the insurance policy on behalf of the insured persons. The number of the insured persons eligible to be insured persons shall not be less than three employees at the start date and each subsequent renewal date.
Article 3
1. Direct insured: all the active full time employees of the policyholder in service.
2. Dependant: the scope of dependant is decided by the policyholder during application that may include the family member(s) of the direct insured:
a. Legal spouse of the direct insured person.
b. Children (aged not more than 18 or up to 28 for those registered as full time students at recognised educational institutions) of an insured person. It is subject to the consent of the insurer and shall be arranged by the policyholder for coverage under this policy.
c. Any other person that the direct insured person agreed to enrol in writing.
However, the insurer will require details of the baby’s medical history if :
– the baby was born within 10 months from the direct insured ‘s start date or the direct insured spouse’s start date, whichever date is later; or
– the baby has been adopted; or
– the baby was born as the result of any method of assisted conception or following any type of fertility treatment, including but not limited to fertility drug treatment.
In such circumstances the insurer reserves the right to apply particular restrictions to the cover the insurer will offer, and the insurer will notify the direct insured of those terms as soon as reasonably possible. This may limit the direct insured baby’s cover for existing medical conditions. This would mean that the direct insured’s baby will not be covered for treatment carried out for medical conditions which existed prior to joining, such as treatment in a Special Care Baby Unit and the direct insured will be liable for these costs.
The insurer can refuse to add a family member to the policy and the insurer will tell the policyholder if the insurer does.
3. Dependants must be covered under the same level of benefits as the direct insured except the insured and the insurer make special restrictions on the medical coverage of the dependent.
4. The direct insured and the dependant in this contract should also be named insured person.
5. This contract will not cover the applicant with US nationality who resides in the US for more than 90 days (including 90 days) every year. In addition, there are some mutually agreed excluded countries that the insurer cannot offer cover if the insured person resides in any of them. Such excluded country list will be communicated to the policyholder prior to the enrolment of the policy.
Article 4
The beneficiary of this insurance contract refers to insured person except for any agreement otherwise.
Article 5 – Benefits
During the insured period of this contract, in case of any medical activities taken in this insurance contract, the insurer shall pay the insurance benefits (i.e. specific benefit will not exceed its corresponding benefit limit and the sum of the benefits paid will not exceed the annual maximum stipulated in the insurance contract) to the insured as follows. All cost actually incurred must be medically necessary and subject to reasonable and customary charges. The Benefits 1 to 24 under the Insurance Liability section are core benefits. The Benefits 25 to 38 under this Insurance Liability section are optional benefits.
1. Hospital Charges, Medical Practitioner and Specialist Fees
a. Charges for in-patient or day-patient treatment made by a hospital including charges for accommodation (ward/semi-private or private); diagnostic tests; operating theatre charges including surgeon and anaesthetist charges; and charges for nursing care by a qualified nurse; drugs and dressings prescribed by
a medical practitioner or specialist; and surgical appliances used by the medical practitioner during surgery. This includes pre and post-operative consultations while an in-patient or day-patient and includes charges for intensive care. The above benefit should be pre-authorised and its maximum benefit should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
b. Actual ancillary charges: purchase and rental of crutches, canes, walking aids and self-propelled
non-electronic wheelchairs within six months of an eligible medical condition which required in-patient or day-patient hospital treatment. The above maximum benefit should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
2. Diagnostic Procedures
The insurer will cover the actual incurred medical charges for the medically necessary diagnostic magnetic resonance imaging (MRI), positron emission tomography (PET) and computerised tomography (CT) scans.
The diagnosis for PET, MRI and CT need to be pre-authorised. The maximum benefit should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
3. Renal Failure and Renal Dialysis
The insurer will cover the actual incurred medical cost of the treatment of renal failure, including renal dialysis on an in-patient, day-patient or out-patient basis. The maximum benefit should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
4. Organ Transplant
The insurer will cover the actual incurred medical costs of the following items:
Treatment for and in relation to a human organ transplant of kidney, pancreas, liver, heart, lung, bone marrow or cornea, in respect of the insured person as a recipient.
In circumstances where an organ transplant is required as a result of a congenital disorder, cover will be provided under Article 5, Benefit 7 – Congenital Disorder but excluded from Article 5, Benefit 4 – Organ Transplant.
The insurer only pays for transplants carried out in internationally-accredited institutions by accredited surgeons and where the organ procurement is in accordance with WHO guidelines.
Medical costs associated with the donor and the cost of the donor organ search are excluded from this Benefit.
The maximum benefits should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
5. Cancer Treatment
The insurer will cover the actual incurred medical cost of the treatment given for cancer received as an in-patient, day-patient or out-patient.
The benefit includes oncologist fees, surgery, radiotherapy and chemotherapy, alone or in combination, from the point of diagnosis. The maximum benefits should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
6. New Born Baby Cover
The insurer will cover the actual incurred medical cost of the in-patient treatment of premature birth (i.e. prior to age 37 weeks gestation) or an acute condition being suffered by a new born baby of an insured person which manifests itself within 30 days following birth. Provided that the new born baby is added to the policy within 30 days of birth and premium paid. Cover for multiple births will be covered up to the same limits agreed.
In circumstances where the insurer requires details of the new born baby’s medical history before the baby is being added to the policy, the insurer reserves the right to apply particular restrictions to the cover the insurer will offer.
Please refer to Article 3 - adding new born of this policy wording for details.
The maximum benefits should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
7. Congenital Disorders
The insurer will cover the actual incurred medical cost of the in-patient treatment for a congenital disorder. In circumstances where a congenital disorder manifests itself in a new born baby within 30 days of birth, cover for such medical conditions will be provided under Article 5, Benefit 6 – New Born Baby Cover but excluded from Article 5, Benefit 7 – Congenital Disorders. The maximum benefits should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
8. Parent Accommodation
The insurer will cover the actual incurred cost of one parent staying in hospital overnight with an insured person under 18 years old while the child is admitted as an in-patient for eligible treatment. The maximum benefit should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
9. Hospital Accommodation for New Born Accompanying their Mother
The insurer will cover the actual incurred medical cost of the hospital accommodation costs relating to a new born baby (up to 16 weeks old) to accompany its mother (being an insured person) while she is receiving eligible treatment as an in-patient in a hospital. The maximum benefits should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
10. Reconstructive Surgery
The insurer will cover the actual incurred medical cost of the reconstructive surgery required to restore natural function or appearance following an accident or following a surgical procedure for an eligible medical condition, which occurred after an insured person’s entry date or start date whichever is later. The maximum benefits should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
11. Day-Patient or Out-Patient Surgery
The insurer will cover the actual incurred treatment costs for a surgical procedure performed in a surgery, hospital, day-care facility or out-patient department. The benefits for such coverage should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
12. In-Patient Emergency Dental Treatment
The insurer will cover the actual incurred medical cost of emergency restorative dental treatment required to sound, natural teeth following an accident which necessitates the insured person’s admission to hospital for at least one night.
The dental treatment must be received within 10 days of the accident. This benefit covers all costs incurred for treatment made necessary by an accidental injury caused by an extra-oral impact, when the following conditions apply:
a. If the treatment involves replacing a crown, bridge facing, veneer or denture, the insurer will pay only the reasonable and customary cost of a replacement of similar type or quality
b. If implants are clinically needed the insurer will pay only the cost which would have been incurred if equivalent bridgework was undertaken instead
c. Damage to dentures providing they were being worn at the time of the injury.
The maximum benefits should be agreed between the policyholder and the insurer and stipulated in the insurance contract.
13. Rehabilitation
The insurer will cover the actual incurred medical rehabilitation cost when referred by a specialist as an integral part of treatment for a medical condition necessitating admission to a recognised rehabilitation unit of a hospital. Where the insured person was confined to a hospital as an in-patient for at least three consecutive days, and where a specialist confirms in writing that rehabilitation is required. Admission to a rehabilitation unit must be made within 14 days of discharge from hospital. Such treatment should be under the direct supervision and control of a specialist and would cover:
a. Use of special treatment rooms
b. Physical therapy fees
c. Speech therapy fees
d. Occupational therapy fees
The maximum benefit for such coverage as well as its maximum number of cover days per medical condition should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
14. Nursing Care at Home
The insurer will cover the actual incurred medical cost of the care given by a qualified nurse in the insured person’s own home, which is immediately received subsequent to treatment as an in-patient or day-patient on the recommendation of medical practitioner or specialist. This coverage needs to be pre-authorised.
The maximum benefit for such coverage and its maximum number of days cover should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
15. Emergency Ambulance Transportation
The insurer will cover the actual incurred emergency road ambulance transport costs to or between hospitals, or when considered medically necessary by a medical practitioner or specialist. The maximum benefit should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
16. Evacuation and Repatriation
The insurer will cover the actual incurred cost of the following:
a. Evacuation
Arrangements will be made to move an insured person who has a critical, life-threatening eligible medical condition to the nearest medical facility for the purpose of admission to hospital as an in-patient or day-patient.
Reasonable expenses for:
i. Transportation costs of an insured person in the event of emergency treatment and medically necessary transport and care not being readily available at the place of the incident. This includes an economy class airfare ticket for a locally-accompanying person who has travelled as an escort.
ii. Reasonable local travel costs to and from medical appointments when treatment is being received as a day-patient.
iii. Reasonable travel costs for a locally-accompanying person to travel to and from the hospital to visit the insured person following admission as an in-patient.
iv. Reasonable costs for non-hospital accommodation only for immediate pre and post-hospital admission periods provided that the insured person is under the care of a specialist.
Costs of evacuation do not extend to include any air-sea rescue or mountain rescue costs that are not incurred at recognised ski resorts or similar winter sports resorts.
The insurer’s medical advisers will decide the most appropriate method of transportation for the evacuation and this benefit will not cover travel cost if it is against the advice of the insurer’s medical advisers or where the medical facility does not have appropriate facilities to treat the eligible medical condition.
b. Repatriation
An economy class airfare ticket to return the insured person and a locally-accompanying person who has travelled as an escort to the site of treatment to the insured person’s principal country of nationality or principal country of residence, as long as the journey is made within one month of completion of treatment. Such transportation cost is only eligible if there was a medical need for an initial evacuation that has taken place.
Deductible would apply to medically necessary treatment required under this benefit.
The above benefit should be pre-authorised. The maximum benefit for such coverage as well as its maximum cost per evacuation should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
17. Mortal Remains
The insurer will cover the actual incurred cost in the event of death from an eligible medical condition, reasonable and customary charges for:
a. Costs of transportation of body or ashes of an insured person to his/her country of nationality or country of residence, or
b. Burial or cremation costs at the place of death in accordance with reasonable and customary practice.
The above benefit should be pre-authorised. The maximum benefits for such coverages should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
18. Emergency Non-Elective Treatment Outside Area Of Cover
For planned trips up to 30 days of duration outside Area Of Cover, the insurer will cover the actual incurred medical cost of a treatment by a medical practitioner or specialist starting within 24 hours of the emergency event, required as a result of an accident or the sudden beginning of a severe illness resulting in a medical condition that presents an immediate threat to the insured person’s health.
The maximum benefit for such coverage as well as its maximum number of cover days per period of cover should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
19. Hospital Cash Benefit
The insurer will cover the benefit payable for each night an insured person receives in-patient treatment and only if:
a. the insured person is admitted for an elective in-patient treatment before midnight and the treatment is received within the public hospitals of the insured person’s country of residence; or
b. this policy being the secondary health insurance policy. However, if the insured person has a RMB 63,000 or RMB 94,500 deductible policy, the insured person is not eligible for the benefit.
Cover under this benefit is limited to a maximum of 30 nights per period of cover. For this benefit exclusion 6.9 does not apply.
The maximum benefits for such coverage should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
20. Out-Patient Charges
The insurer will cover the actual incurred medical cost of:
a. Medical Practitioner fees including consultations; Specialist fees; Diagnostic Tests;
b. Teleconsultation (Virtual Doctor appointments via electronic means).
Costs associated with Eligible Treatment will be paid in full where Treatment is received from Medical Providers listed in the SimpleCare Comprehensive Network.
Treatment that is not received in the SimpleCare Comprehensive Network will pay Reasonable & Customary charges.
c. Prescribed Drugs and Dressings.
d. Vitamins and Minerals:
Vitamins and Minerals as prescribed by a Medical Practitioner. Vitamins prescribed for a diagnosed deficiency will be paid as per the Out-Patient Benefit.
Any pre-operative and post-hospitalisation consultations are payable under this Benefit.
The insured does not have cover for costs relating to the maintenance of Chronic Conditions unless the insured is insured under SimpleCare Jade or SimpleCare Crystal, which the insurer will pay such eligible costs under Article 5, Benefit 20 – Out-Patient Charges.
Please note: If claim receipts do not show a breakdown of the medical services rendered, We will only pay Eligible claims up to the Prescribed Drugs and Dressings limit.
Annual Out-Patient Limit is applicable to Benefit 20- Out-Patient Charges and Benefit 21 - Out-Patient Physiotherapy and Alternative Therapies only, subject to Annual Maximum Policy Limit.
The maximum benefit for such coverage as well as its maximum session per period of cover should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
21. Out-Patient Physiotherapy and Alternative Therapies
The insurer will cover the actual incurred medical cost of:
a. Physiotherapy by a Registered Physiotherapist.
b. Complementary medicine and treatment by a therapist. This benefit extends to chiropractors, chiropodists and podiatrists, osteopaths, homeopaths, dietician and acupuncture treatment.
c. Out-Patient Treatment for therapies administered by a recognised traditional Chinese Medical Practitioner or an Ayurvedic Medical Practitioner.
You may choose 5 sessions for any combination of benefits in aggregate in a given period of cover for benefits
a. and b. excluding dietician without the need of referral; any subsequent sessions need to be referred by a medical practitioner or specialist.
Annual Out-Patient Limit is applicable to Benefit 20- Out-Patient Charges and Benefit 21 - Out-Patient Physiotherapy and Alternative Therapies only, subject to Annual Maximum Policy Limit.
The maximum benefit for such coverage and its maximum number of visits per period of cover should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
22. Menopause Hormone Replacement Therapy
The insurer will cover the cost of Hormone Replacement Therapy when required to alleviate the symptoms of the early onset of menopause where onset and treatment commence below the age of 40 years. The maximum benefit per period of cover should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
23. Out-Patient Psychiatric Illness
The insurer will cover the actual incurred medical cost of out patient treatment administered by a registered psychologist and/or a registered psychiatrist, subject to 10 sessions and the cost limit under this section.
For the first 5 sessions you may choose to visit a registered psychologist directly without the need for referral. However, any subsequent sessions with a registered psychologist will require referral and a treatment plan with a medical practitioner or specialist.
The maximum benefit for such coverage as well as its maximum session per period of cover should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
24. Dental Care
The insurer will cover the actual incurred medical cost of:
Fees of a registered Dental Practitioner carrying out dental Treatment in a dental clinic/surgery. This Benefit provides cover for the below dental Treatment:
– Screening (including x-rays where necessary)
– Preventive scaling, polishing, and sealing (once per year)
– Fillings and extractions (non-surgical and surgical)
– Root canal treatment
– New or repair of crowns, dentures, in lays and bridges
– Apicoectomy
Dental implants and orthodontics Treatment are specifically excluded under this Benefit.
No other Treatment is covered by this Benefit.
Waiting period: Any expenses incurred within 180 days after the start date of the insured person’s policy are not payable. The insured person must have completed the waiting period of 180 days before the benefit is payable irrespective of whether the policyholder renews the insurance or not.
A co-insurance of 20% applies.
For this benefit, the deductible or out-patient per visit excess does not apply.
The maximum benefit per period of cover should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
25. Mainland China option
The insurer will cover the actual incurred medical costs associated with all eligible in-patient, day-patient, and out-patient treatment restricted to Mainland China and will be subject to the standard policy limits.
Emergency non elective treatment outside of Mainland China:
For planned trips up to 30 days of duration. Treatment by a medical practitioner or specialist starting within
24 hours of the emergency event, required as a result of an accident or the sudden beginning of a severe illness resulting in a medical condition that presents an immediate threat to the insured person’s health.
Full Refund for accident requiring in-patient and day-patient care.
Illness: in-patient and day-patient care up to a mutually agreed amount per period of cover.
The maximum benefit should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
26. Hospital Room Restriction – Hospital Room & Board Limit RMB 800
As described in Article 5 Benefit 1 a) on the insurance contract, but with a restriction to limit the hospital accommodation for hospital admission in Mainland China up to RMB 800 per day for any charge for eligible
in-patient or day-patient treatment made by the hospital and by any medical practitioner, should the in-patient or day-patient be received in any in-patient/day-patient facility in Mainland China as pre-defined and advised by the insurer.
The maximum benefit should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
27. High Cost Provider Restriction
The insurer will not cover the actual incurred medical costs associated with eligible in-patient, day-patient or out-patient treatment made by the hospital, and by any medical professional, should the in-patient, day-patient or out-patient treatment be received in any high cost in-patient/day-patient facility in Mainland China as
pre-defined and advised by the insurer.
28. In-Patient Co-Insurance at Private Hospital
The insurer will cover the actual medical costs associated with the benefits for eligible in-patient or day-patient treatment at a private hospital subject to 20% co-insurance.
The benefit should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
29. Annual Maximum Policy Limit RMB 1,000,000
During the insured period of this contract, in case of any medical activities taken in this insurance contract, the insurer shall pay the insurance benefits (i.e. specific benefit will not exceed its corresponding benefit limit and the sum of the benefits paid will not exceed the annual maximum policy limit of RMB 1,000,000.
30. Co-Insurance Out-Patient Treatment
The insurer will cover the actual incurred medical cost with a 20% co-insurance on all eligible out-patient treatment.
Co-insurance does not apply to cancer treatment, organ transplant or renal failure and renal dialysis.
This option is not available for Group Plans with deductibles of RMB 6,300 or higher. The maximum benefit should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
Should the plan includes maternity, dental care or wellness and vaccinations benefits, any applicable co-insurance will be detailed in insured person’s benefit schedule.
31. Out-Patient Per Visit Excess
An RMB 150 out-patient per visit excess will apply when the insured person receives eligible out-patient treatment.
The out-patient per visit excess would apply to both Article 5, Benefits 20 - Out-Patient Charges and Benefits 21 – Out-Patient Physiotherapy and Alternative Therapies Benefits.
This option is not available for Group Plans with deductibles of RMB 6,300 or higher.
The maximum benefit should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
32. Removal of Drugs and Dressings Limit
By selecting this option, cover for Prescribed Drugs and Dressings under Benefit 20 c) will be Full Refund, subject to annual Out-Patient limit.
For Compulsory Group Plans 3+ employees
The maximum benefit should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
33. Wellness and Vaccinations – Option 1
The insurer will cover the actual incurred medical costs associated with:
a. Wellness: this benefit is payable as a contribution towards the cost of routine health checks including cancer screening, BRCA I & II Test (where a direct family history exists), bone densitometry (once every five years for women aged 50+), cardiovascular examination, neurological examinations, vital signs (e.g. blood pressure, body mass index, urinalysis, cholesterol), well child test (Up to age of 5 Years), and/or
b. Vaccinations: cost of drugs and consultations to administer all medically necessary basic immunisation and booster injections and any medically necessary travel vaccinations and malaria prophylaxis.
This clause applies to compulsory group policies of 3+ employees. For this benefit exclusion 6.9 does not apply. The maximum benefit should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
34. Wellness and Vaccinations – Option 2
The insurer will cover the actual incurred medical costs associated with:
a. Wellness: this benefit is payable as a contribution towards the cost of routine health checks including cancer screening, BRCA I & II Test (where a direct family history exists), bone densitometry (once every five years for women aged 50+), cardiovascular examination, neurological examinations, vital signs (e.g. blood pressure, body mass index, urinalysis, cholesterol), well child test (Up to age of 5 Years), and/or
b. Vaccinations: cost of drugs and consultations to administer all medically necessary basic immunisation and booster injections and any medically necessary travel vaccinations and malaria prophylaxis.
This clause applies to compulsory group policies of 3+ employees. For this benefit exclusion 6.9 does not apply. The maximum benefit should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
35. Maternity – Option 1
The insurer will cover:
a. Medically Necessary costs incurred during Pregnancy and childbirth: childbirth costs, including pre and post-natal check-ups for up to six weeks following birth, scans and delivery costs for a natural birth or voluntary/Emergency caesarean section. Paediatrician costs for the first examination/check-up of a New Born baby, if the examination is made within 24 hours of delivery and Well-baby examinations up to the child’s second birthday and as recommended by a Medical Practitioner or Specialist. This includes physical examinations, measurements, sensory screening, neuropsychiatric evaluation, development screening, as well as hereditary and metabolic screening, immunisations, urine analysis, tuberculin tests and hematocrit, haemoglobin and other blood tests, including tests to screen for sickle haemoglobinopathy. Please note We will pay for the above Well-baby examinations costs only if We have paid the delivery cost of the baby under this Group Plan, provided the baby is being added into the Group Plan as an Insured Person.
b. For In-Patient Treatment of an Eligible Medical Condition which arises during the antenatal stages of Pregnancy or an Eligible Medical Condition which arises during childbirth, the insurer would only allow Treatment of the following as an Eligible Medical Condition under this Benefit b):
– Ectopic pregnancy (where the foetus is growing outside the womb)
– Hydatidiform mole (abnormal cell growth in the womb)
– Retained placenta (afterbirth retained in the womb)
– Placenta praevia
– Eclampsia (a coma or seizure during pregnancy and following pre-eclampsia)
– Diabetes (If the insured person has exclusions because of the insured person’s past medical history which relate to diabetes, then the insured person will not be covered for any treatment for diabetes during pregnancy)
– Post partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth)
– Miscarriage requiring immediate surgical treatment
This benefit b) does not provide any cover for voluntary/ Emergency caesarean section procedures or ‘failure to progress in labour’ unless for one of the above stated Eligible Medical Conditions.
Waiting period: Any expenses incurred within 180 days after the start date of the insured person’s policy are not payable. For the expenses incurred after the 180th day to one year after the policy takes effect, this benefit has a 95% co-insurance. The insured person must have completed the waiting period of 180 days before the benefit is payable irrespective of whether the policyholder renews the insurance or not.
Please note, the insurer does not pay for parenting or other teaching classes as these are a matter of personal choice.
For Compulsory Group Plans 10+ employees. For this benefit exclusion 6.27 does not apply. Deductible would apply to this benefit.
The maximum benefit per period of cover should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
36. Maternity – Option 2
The insurer will cover:
a. Medically Necessary costs incurred during Pregnancy and childbirth: childbirth costs, including pre and post-natal check-ups for up to six weeks following birth, scans and delivery costs for a natural birth or voluntary/Emergency caesarean section. Paediatrician costs for the first examination/check-up of a New Born baby, if the examination is made within 24 hours of delivery and Well-baby examinations up to the child’s second birthday and as recommended by a Medical Practitioner or Specialist. This includes physical examinations, measurements, sensory screening, neuropsychiatric evaluation, development screening, as well as hereditary and metabolic screening, immunisations, urine analysis, tuberculin tests and hematocrit, haemoglobin and other blood tests, including tests to screen for sickle haemoglobinopathy. Please note We will pay for the above Well-baby examinations costs only if We have paid the delivery cost of the baby under this Group Plan, provided the baby is being added into the Group Plan as an Insured Person.
b. For In-Patient Treatment of an Eligible Medical Condition which arises during the antenatal stages of Pregnancy or an Eligible Medical Condition which arises during childbirth, the insurer would only allow Treatment of the following as an Eligible Medical Condition under this Benefit b):
– Ectopic pregnancy (where the foetus is growing outside the womb)
– Hydatidiform mole (abnormal cell growth in the womb)
– Retained placenta (afterbirth retained in the womb)
– Placenta praevia
– Eclampsia (a coma or seizure during pregnancy and following pre-eclampsia)
– Diabetes (If the insured person has exclusions because of the insured person’s past medical history which relate to diabetes, then the insured person will not be covered for any treatment for diabetes during pregnancy)
– Post partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth)
– Miscarriage requiring immediate surgical treatment
This benefit b) does not provide any cover for voluntary/ Emergency caesarean section procedures or ‘failure to progress in labour’ unless for one of the above stated Eligible Medical Conditions.
Waiting period: Any expenses incurred within 180 days after the start date of the insured person’s policy are not payable. For the expenses incurred after the 180th day to one year after the policy takes effect, this benefit has a 95% co-insurance. The insured person must have completed the waiting period of 180 days before the benefit is payable irrespective of whether the policyholder renews the insurance or not.
Please note, the insurer does not pay for parenting or other teaching classes as these are a matter of personal choice.
For Compulsory Group Plans 10+ employees. For this benefit exclusion 6.27 does not apply. Deductible would apply to this benefit.
The maximum benefit per period of cover should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
37. Capped Cover for Declared Pre-existing Medical Conditions
For Compulsory Group Plans 5 to 19 employees.
This underwriting option provides limited cover for any pre-existing Medical Conditions that are declared and accepted by Us.
Waiting period: Any expenses incurred within 180 days after the start date of the insured Person’s policy are not payable. The insured person must have completed the waiting period of 180 days before the benefit is payable irrespective of whether the policyholder renews the insurance or not.
The maximum benefit per period of cover should be mutually agreed between the policyholder and insurer and stipulated in the insurance contract.
38. Medical History Disregarded
This clause applies to compulsory group policies of 10+ employees.
3. Exclusions
Article 6 – Exclusions
The insurer will not bear any liabilities for insurance claim compensation if the following treatments or expense fees are incurred by the insured person or the dependant as a result of any of the following
situations even though the medical activities have obtained the prescription, recommendation or consent of physician or dentist. Also, below are group policy exclusions that apply in addition to any personal exclusions detailed in the insured person’s certificate of insurance.
6.1 Act of terrorism, war and illegal acts
The insurer will not pay for treatment of any condition resulting directly or indirectly from, or as a consequence of war, acts of foreign hostilities (whether or not war is declared) civil war, rebellion, revolution, insurrection or military or usurped power, mutiny, riot, strike, martial law or state of siege, or attempted overthrow of government, or any acts of terrorism, unless the insured person is an innocent bystander. The insured person is not covered for costs arising from taking part in any illegal act.
6.2 Administrative and shipping fees
The insured person is not covered for any charges made by a medical practitioner or dental practitioner for filling in claim forms or providing medical reports. The insured person is not covered for any charges where a police report is required. The insured person is not covered for the cost of shipping (including customs duty) on transporting medication.
6.3 Alcohol and drug abuse
The insured person is not covered for costs for treatment resulting from dependency on or abuse of alcohol, drugs, or other addictive substances and any illness or injury arising directly or indirectly from such dependency or abuse.
6.4 Chemical exposure
The insured person is not covered for treatment costs directly or indirectly caused by or contributed to or arising from: ionizing radiations or contamination by radioactivity from any nuclear waste from the combustion of nuclear fuel; the radioactive, toxic, explosive or other hazardous properties of any explosive nuclear assembly or nuclear component thereof.
6.5 Cosmetic treatment
The insured person is not covered for treatment costs relating to cosmetic or aesthetic treatment or any treatment related to previous cosmetic or reconstructive surgery (whether or not for psychological purposes) to enhance your appearance, even when medically prescribed, such as but not limited to acne, teeth whitening, lentigo and alopecia.
The only exception is an initial reconstructive surgery necessary to restore function or appearance after a disfiguring accident, or following a surgical procedure for an eligible medical condition, if the accident or surgery occurs during the insured person’s membership.
6.6 Contamination
The insured person is not covered for the treatment of any conditions, or for any claim arising directly or indirectly from chemical or biological contamination, however caused, or from contamination by radioactivity from any nuclear material whatsoever, asbestosis, including expenses in any way caused by or contributed to by an act of war or terrorism.
6.7 Chronic conditions
The insured does not have cover for costs relating to the maintenance of Chronic Conditions unless the insured is insured under SimpleCare Jade or SimpleCare Crystal, which the insurer will pay such eligible costs under Article 5, Benefit 20 – Out-Patient Charges.
6.8 Coma or Vegetative State
We will not pay for any treatment costs incurred by an insured person after being in a coma or in a vegetative state for more than 12 months. We will, however, pay for any active treatment costs of an eligible medical condition incurred within the first 12 months of the coma or the vegetative state.
6.9 Deductible, out-patient per visit excess or co-insurance
The insured person is not covered for the amount of the deductible, out-patient per visit excess or co-insurance that is shown on the insured person’s certificate of insurance. The insurer will treat any arrangement with or any offer by a provider to charge the insurer a higher fee to cover the amount of the deductible, out-patient per visit excess or co-insurance as fraud and the insurer will take legal action.
6.10 Dental care
The insured person is not covered for any dental care unless these benefits are included on the insured person’s certificate of insurance. However the insurer will pay for emergency in-patient dental treatment following an accident as detailed in the benefit schedule. The insurer will not pay for any telephone or travelling expenses incurred in seeking dental advice or treatment, damage to dentures unless being worn at the time of the accident, or the cost of treatment made necessary by an accidental dental injury if:
– The injury was caused by eating or drinking anything, even if it contains a foreign body
– The damage was caused by normal wear and tear
– The injury was caused when boxing or playing rugby (except school rugby) unless appropriate mouth protection was worn
– The injury was caused by any means other than extra-oral impact
– The damage was caused by tooth brushing or any other oral hygiene procedure
– The damage is not apparent within 10 days of the impact which caused the injury
– The costs are incurred more than 18 months after the date of the injury which made the treatment necessary.
6.11 Developmental disorders
The insured person is not covered for treatment of developmental, behavioural or learning problems such as attention deficit hyperactivity disorder, speech disorders or dyslexia and physical developmental problems.
6.12 Dietary supplements and cosmetic products
The insured person is not covered for nutritional or dietary consultations and supplements, including, but not limited to, special infant formula and cosmetic products including but not limited to moisturizers, cleansers, lotions, soaps, shampoos, sunscreen, mouth wash, antiseptic lozenges, even if medically recommended or prescribed or acknowledged as having therapeutic effects.
6.13 Eating disorders
The insured person is not covered for costs relating to treatment of eating disorders such as, but not limited to, anorexia nervosa and bulimia.
6.14 Experimental treatment and drugs
The insured person is not covered for treatment or drugs which have not been established as being effective or which are experimental. For drugs this means they must be licensed for use by the appropriate Medicines Agency or the Medicines and Healthcare products Regulatory Agency and be used within the terms of that license. For established treatment, this means procedures and practices that have undergone appropriate clinical trial and assessment, sufficiently evidenced and published medical journals and/or approved by the appropriate National Institute for Health and Clinical Excellence for specific purposes to be considered proven safe and effective therapies.
6.15 Eyesight tests or vision correction, hearing tests, hearing or visual aids
You are not covered for routine eyesight or hearing tests or the cost of eyeglasses, contact lenses, hearing aids or cochlear implants. We do not pay for eye surgery to correct vision, however eye surgery to correct an Eligible Medical Condition is covered.
6.16 External appliance and or prosthesis
The insured person is not covered for any costs relating to providing, maintaining and fitting of any external prosthesis or appliance or other equipment, medical or otherwise except as is specified under the Hospital Charges, Medical Practitioner and Specialists fees benefit.
6.17 Failure to follow medical advice
The insured person is not covered for treatment arising from or related to the insured person’s unreasonable failure to seek or follow medical advice and/or prescribed treatment, or the insured person’s unreasonable delay in seeking or following such medical advice and/or prescribed treatment. The insurer will not pay for complications arising from ignoring such advice.
6.18 Foetal surgery
The insured person is not covered for the costs of surgery on a child while in its mother’s womb except as part of the maternity benefits detailed in the insured person’s certificate of insurance.
6.19 Genetic testing
The insured person is not covered for the cost of genetic tests, when those tests are undertaken to establish whether or not the insured person may be genetically disposed to the development of a medical condition, whether the insured person has a medical condition when he/she has no symptoms or if there is a genetic risk of the insured person passing on a medical condition.
6.20 Hazardous sports and pursuits
The insured person is not covered for treatment of injuries sustained from base jumping, cliff diving, motor sports, 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 30 metres, trekking to a height of over 4,000 metres, bungee jumping, canyoning, hang-gliding, paragliding or microlighting, parachuting, potholing, skiing off piste or any other winter sports activity carried out off piste.
6.21 HIV, AIDS or sexually transmitted disease
The insured person is not covered for treatment for Acquired Immune Deficiency Syndrome (AIDS), AIDS-related Complex Syndrome (ARCS) and all diseases caused by or related to Human Immunodeficiency Virus (HIV) (or both) and sexually transmitted disease. HIV test when not medically prescribed or screening for visa application purposes are not covered.
6.22 Hormone replacement therapy
The insured person is not covered for the costs of treatment for hormone replacement therapy.
The insured person is covered for medical practitioner’s fees including consultations, the cost of implants, patches or tablets which are medically necessary as a direct result of medical intervention, up to a maximum of 18 months from the date of medical intervention and for Menopause Hormone Replacement Therapy where onset and treatment commence below the age of 40 years.
6.23 Morbid obesity
The insured person is not covered for the costs of treatment for, or related to, morbid obesity.
The insured person is not covered for costs arising from or relating to removing fat or surplus healthy tissue from any part of the body.
6.24 Nursing homes, convalescence homes, health hydros, and nature cure clinics
The insured person is not covered for treatment received in nursing homes, convalescence homes, health hydros, nature cure clinics or similar establishments. The insured person is not covered for convalescence or where the insured person is in hospital for the purpose of supervision. The insured person is not covered for extended nursing care if the reason for the extended nursing care is due to age related infirmity and/or if the hospital has effectively become the insured person’s home.
6.25 Palliative and Hospice care
The insured, on diagnosis of a terminal illness by a medical practitioner or specialist, is not covered for the costs of Hospital or Hospice accommodation or costs of any other treatment for the purpose of offering temporary relief of symptoms.
6.26 Pre-existing medical conditions
The insured person is not covered for treatment of pre-existing medical conditions and related conditions unless accepted by the insurer in writing.
A pre-existing medical condition means any disease, injury or illness for which:
1. The insured person has received treatment, tests or investigations for, been diagnosed with or been hospitalised for; or
2. The insured person has suffered from or experienced symptoms; whether the medical condition has been diagnosed or not, at any time before the insured person’s start date/entry date into the policy.
6.27 Pregnancy or maternity
The insured person is not covered for costs relating to pregnancy or childbirth, medically necessary and/or emergency caesarean section, voluntary caesarean section, unless maternity benefits a) are shown on the insured person’s insurance policy or certificate of insurance.
These costs are only covered under the maternity benefit a) and are not covered or recoverable under any other benefits.
6.28 Professional sports
The insured person is not covered for any costs resulting from injuries or illness arising from the insured person taking part in any form of professional sport. By professional sport, the insurer means where the insured person is being paid to take part.
6.29 Psychiatric or Psychological Treatment
You are not covered for Treatment costs related to psychiatric illness or any psychological conditions unless specified in your benefit schedule.
6.30 Reproductive treatment and drugs
The insured person is not covered for costs relating to investigations into or treatment of infertility and fertility, sterilisation (or its reversal) or assisted conception. The insured person is not covered for the costs in connection with contraception.
6.31 Routine examinations, health screening and Vaccinations
You are not covered for routine medical examinations (including issuing medical certificates, health screening examinations or tests to rule out the existence of a condition for which You do not have any symptoms) and any types of Vaccination costs. (unless benefits are shown on the insured person’s certificate of insurance.)
6.32 Second opinions
The insured person is not covered for the costs of any second or subsequent medical opinions from a medical practitioner or specialist for the same medical condition other than stated in the insured person’s certificate of insurance, unless authorised by the insurer.
6.33 Self-inflicted injuries or attempted suicide
The insured person is not covered for any costs for treatment resulting directly or indirectly from self-inflicted injury, suicide or attempted suicide.
6.34 Sexual problems and gender re-assignment
The insured person is not covered for treatment costs relating to sexual problems including sexual dysfunction, or 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. The insured person is not covered for the costs of treating sexually transmitted infections.
6.35 Sleep disorders
The insured person is not covered for treatment costs related to snoring, insomnia, jet-lag, fatigue, or sleep apnoea including sleep studies or corrective surgery.
6.36 Travel/accommodation costs
The insured person is not covered for transport or accommodation costs the insured person incurs during trips made specifically to get medical treatment unless these costs are for an emergency medical evacuation that the insurer pre-authorises. The insured person is not covered for any costs of emergency medical evacuation or repatriating the insured person’s body that the insurer did not
pre-authorise and arrange.
6.37 Travelling against medical advice
The insured person is not covered for medical or other costs the insured person incurs if the insured person travels against the advice given by the insured person’s treating medical practitioner.
6.38 Treatment in High Cost Medical Facilities
The insured person is not covered for costs of treatment incurred in any medical provider that is listed in the insurer’s high cost providers list.
6.39 Treatment by a family member
The insured person is not covered for the costs of treatment by a family member or for self-therapy.
6.40 Treatment charges outside of our reasonable and customary range
The insured person is not covered for treatment charges when they are above the reasonable and customary charges level.
18 | SimpleCare Policy Wording (April 2024) | Insurance Sum Assured and Insurance Premium, Coverage Period
4. Insurance Sum Assured and Insurance Premium
5. Coverage Period
Article 7 – Insurance Sum Assured and Insurance Premium
1. The insurance sum assured stated in this contract is the maximum liability for the insurer to cover. During the insurance contract’s coverage period, the amount of benefit that the insurer covers for each item shall not be higher than its maximum sum assured per item, and the accumulated amount of benefits shall not be higher than the total sum assured. The total insurance sum assured and the maximum sum assured per coverage are mutually agreed by the insurer and the policyholder, and stated in the insurance policy.
2. The policyholder is responsible for paying the insurance premium according to the insurance contract.
3. The insurance premium is calculated as per the agreed sum assured and its premium rate stated in the insurance contract.
Article 8 – Coverage Period and Renewal
The insurance coverage period shall be one year.
This insurance contract is non-guaranteed at renewal. Upon the expiry of the insurance period, the policyholder needs to reapply for this product from the insurer, get insurer approval, pay the insurance premium and receive a new insurance contract.
Article 9 – Waiting Period
Waiting Period is referred to after the policy effective date or the policy issued date (whichever is later). The insurer does not bear for insurance liability for a period of time. The exact number of days should be agreed between the insurer and the policyholder. However, the waiting period cannot be exceeded 180 days. The insured person must have completed the waiting period before the benefit is payable irrespective of whether the policyholder renews the insurance or not.
Article 10 – Deductibles
The insurance product is designed to have deductible options. The agreed deductibles will apply when
the insured person receives eligible in-patient, day-patient and out-patient treatment (for treatment inside and outside of the provider network).
If the policyholder has selected a deductible option, the policyholder is required to select either a co-insurance out-patient treatment option or an out-patient per visit excess option.
The amount of the deductible and the option to be taken together with the deductible option should be mutually agreed between the policyholder and the insurer and stipulated in the insurance contract.
6. Insurer’s Obligations
Article 11 – Clear Disclosure
When the insurance contract is being established, since the policy wording content is a standard version, the insurer will enclose the standard policy wording, and explain and disclose all the terms and conditions to the policyholder. In particular related to the exclusion clauses in the contract, the insurer will provide clear
reminders in the individual application form and policy. There will also be verbal or written explanations about this particular clause. Without that, such exclusion is not enforceable.
Article 12 – Policy Issuance
The insurer shall issue an insurance policy or other insurance certificates to the policyholder in time after the insurance contract is established.
Article 13 – Request for Further Claim Details
If the insurer thinks that the evidence of claim submissions and information provided is not sufficient, the insurer will inform the policyholder/insured person promptly of the required supplementary information at one time.
Article 14 – Prompt Claim Assessment and Payment Obligations
After the insurer receives the claim submission applications from the insured person or beneficiary, the insurer shall review and determine in time if it is under insurance cover. For complicated cases, the insurer shall determine within 30 days unless there is another agreement in the insurance contract.
The insurer shall notify the claim assessment result to the insured person or beneficiary. If the claim application request is under the policy coverage, the insurer shall perform the obligation of paying the claim reimbursement within 10 days after the insurer reaches agreement on the insurance claim payment with the insured person or beneficiary. In case of any other agreement on the claim payment period, the insurer shall perform its obligations
to pay the insurance claim amount as per the agreement. The insurer shall issue a decline letter with reason in three days from the date of determinations if the request is not covered.
Article 15 – Claim Settlement during Validity Period
The insurer shall pay in advance the claim amount confirmed as per the existing available proofs and information within 60 days from the date insurer receives the request and related certificates or materials for payment of insurance claim amount. In case that the total amount of payment cannot be determined, the insurer shall settle the claim balance after the final amount is confirmed.
7. Policyholder, Insured Person and Beneficiary’s Obligations
Article 16 – Premium Payment
The insurance premium payment method in the insurance contract should be agreed between the policyholder and the insurer during the insurance application stage. Also, the insurance premium payment method should be indicated clearly in the certificate of insurance.
If the agreed insurance premium payment method is paid annually, the policyholder is required to pay all the insurance premium once the policy has been set up. If the policyholder does not pay the insurance premium on time as agreed, the insurance contract is not valid.
If the agreed insurance premium payment method is paid by installments, the policyholder should apply and is required to be agreed by insurer. The payment cycle of installment is required to be indicated clearly in the
insurance contract. Policyholder should pay the 1st installment of insurance premium on time as agreed. If the policyholder does not pay the 1st installment of insurance premium on time as agreed, the insurance contract is not valid.
If the policyholder does not pay the insurance premium from the 2nd installment onwards or any installment afterwards on time as agreed in insurance contract and the policyholder does not pay the insurance premium for the said installment within 30 days following the insurer sending reminder date, this insurance contract is terminated.
If there is any insurance incident happened before the termination of the insurance contract, the insurer is required to reimburse the claims in accordance with the terms and conditions of insurance policy. However, the outstanding insurance premium of the policyholder should be deducted from the reimbursed amount.
The sum of premium paid by policyholder and the premium deducted by insurer should be same as the total premium amount mentioned in the insurance contract.
The policyholder shall be responsible for the payment of the premium for all eligible insured persons included in this agreement.
Article 17 – Full and Frank Disclosure
Upon establishment of the insurance contract, should the insurer have inquiries on relevant conditions regarding the policyholder/insured person, the policyholder should provide full and frank disclosure to the insurer.
Should the policyholder fail to perform its obligation of full and frank disclosure by intention or due to material default attributable to influence the insurer’s decision on underwriting the insurance proposal or increasing the premium rate, the insurer is entitled to terminate the contract.
Should the insurer fail to exercise the termination right as mentioned above within 30 days upon knowing the cause should be deemed as waiver of such right.
Should the policyholder fail to perform its obligation of full and frank disclosure intentionally, the insurer is not liable for any claim payment of the insured incident that happened before the termination of the contract, and shall not refund the premium.
Should the policyholder fail to perform its obligation of full and frank disclosure due to material default, significantly attributable to the occurrence of the insured incident, the insurer shall not be liable for
the claim payment of the insured incident that happened before the termination of the contract, but shall refund the insurance premium.
The insurer cannot terminate the insurance contract if the insurer is aware of the situation that the policyholder has failed to provide full and frank disclosure upon execution of the contract. If there is an insured incident,
the insurer should be responsible for the claim benefit payment.
Article 18 – Change of Address or Notification Method
If there is a change of the policyholder’s resident address or communication method, the policyholder shall inform the insurer in a timely manner by providing written notification to the insurer. If the policyholder fails to inform the insurer, the insurer shall send notice to the last known address and it would be considered that the notice has been sent to the policyholder.
Article 19 – Insured Incident Notification
The policyholder, the insured person or the beneficiary shall notify the insurer in a timely manner when they are aware of an occurrence of the insured incident. Should the policyholder, insured person or beneficiary deliberately fail to disclose any matter relating to an insured incident or fail to disclose any material issue relating to the insured incident to the insurer of such insured incident which causes difficulty in the identification of the nature of the incident, cause, degree of loss, etc. in a timely manner, the insurer is not liable to the claim payment for the portion that cannot be identified, with exception to the case where the insurer had known or ought to have known such insured incident through other channels.
The above obligation does not include the delay caused by force majeure.
8. Claim and Payment of Insurance Compensation
Article 20 – Claim Application
The applicant of claim payment should provide the following materials when submitting their claim to the insurer. The applicant should provide other required legal or related materials if the applicant is not able to provide the following materials for any special reasons. If the applicant is not able to provide materials so as the insurer
is unable to confirm the authenticity of the claim application, the insurer should not undertake the liability of compensation for the portion that is unable to be determined:
a. Claim application form;
b. Insurance policy or policyholder’s certificate;
c. Applicant’s legitimate and effective identity certificate;
d. Medical receipts issued by the hospital (emergency treatment stamp of the hospital is required for medical expense receipts for emergency treatment), original diagnosis certificate and medical records;
e. For medical evacuation, a written documentary proof issued by the legitimate rescue organisation recognised by the insured should be provided;
f. Other supporting documents and information related to confirmation of the nature, cause and degree of injury, etc.
Article 21 – Right of Claims
The applicant’s right of claims will be subject to the currently valid legal provisions.
Article 22 – Compensation Principle
The payment of benefits under this insurance policy shall apply according to the following compensation principle.
1) If the insured has obtained relevant medical expenses compensation from other channels (including but not restricted to social basic medical insurance, public medical insurance, medical insurance under employee benefits), the insurer will only pay the balance of the cost of the medical treatment, in accordance with the provisions of this insurance contract, after compensation has been obtained from other channels (including but not restricted to social basic medical insurance, public medical insurance, medical insurance under employee benefits).
2) If the insured is a member of social basic medical insurance or public medical insurance, but fails to get compensation in social basic medical insurance or public medical insurance when making a claim, the insurer will protect the rights and interests of the applicant according to the applicant’s insurance certificate and policy, subject to the upper limit under the coverage and the compensation standards stated on the insurance certificate and the policy.
9. Dispute Resolution and Applicable Law
Article 23 – Dispute Resolution
Disputes arising from the performance of this contract should be resolved through the consultations by the parties concerned. If the dispute cannot be resolved between the parties having exhausted all resonable attempts to do so, the disputes should be submitted to the People’s Court of Litigation for its ultimate and binding decision on
all parties.
Article 24 – Applicable Law
The law of the People’s Republic of China shall be applicable to this insurance contract as well as any dispute related to the performance of this contract (laws of HK, Macau, and Taiwan are excluded).
10. Miscellaneous
Article 25 – Continuous Transfer Terms
The insurer will maintain the insured person’s existing underwriting or special acceptance terms, as shown by the insured person’s current insurer, such as any moratoria or specific exclusions and the insured person’s group policy with the insurer will be governed by the terms and conditions of this group policy. The acceptance by the insurer of the insured person’s original entry date will be applied to the insured person’s group policy with
the insurer and any transfer will be subject to no enhanced benefits being provided. The above term is subject to the insurer’s written approval.
Should the insured person’s group policy come to an end the insured person can apply to transfer to one of
the insurer’s individual plans. The insured person’s applications must be submitted to the insurer before the insured person leaves the group policy and acceptance is subject to written agreement from the insurer.
Article 26 – Termination of Contract
The policyholder may cancel this policy by contacting the insurer during the 14 day cooling off period. The 14 day cooling off period starts on the date that the contract is concluded or the day that full policy terms and conditions are received, whichever is the later. The 14 day cooling off period also applies from each renewal date. If the policy is cancelled during the 14 day cooling off period the insurer will return any premium paid for the policy
to the policyholder providing no claims have been made on the policy in relation to the period of cover before cancellation (being no more than 14 days’ cover). If eligible claims costs are incurred within that period of cover the insurer reserves the right to require the policyholder to pay for the services provided in connection with
the policy to the extent permitted by law and any return of premium is subject to this.
Upon the formation of the insurance contract, the policyholder may provide written notice to the insurer to terminate this contract with the exception that the insurer has paid the insurance claim compensation expense as per the agreement of the contract.
When the policyholder requires termination of this contract, they should provide the following certificates and documents:
a. Original copy of the insurance policy
b. Insurance premium payment certificate
c. Effective identification proof of the policyholder
d. Any other insurance contract related documents and information that could be provided by the policyholder.
This contract terminates upon the receipt of the termination application, related proofs and documentations by the insurer.
Within 30 days from the date of receipt of the above mentioned documents, the insurer will refund the minimum cash value of the insurance policy of the contract to the policyholder.
Any termination of this agreement shall be without prejudice to any accrued rights and obligations of both parties in respect of the period for which the premium has been paid.
Article 27 – Use of Membership Card
26.1 The direct billing membership card is the insurer’s property. It can only be used for the purpose of receiving direct billing for medical treatment covered under the terms and conditions of the Policy and the Member Handbook.
26.2 Under no circumstance may an insured person use the direct billing membership card to receive medical treatment related to a personal exclusion and/or an exclusion as listed under Article 6 – Exclusions of
the Policy. The insurer will not be liable for any misuse by his/her of such direct billing membership cards.
26.3 If an insured person receives treatment that is not eligible under the policy through out-patient direct billing, the insured person is first liable for the costs incurred and the insured person must provide a refund to
the insurer within 15 working days from the date of request of reimbursement by the insurer. The insurer may offset valid claims against outstanding funds due to the insurer or the insurer may suspend the insured person’s benefits until the insured person has settled the outstanding amounts in full.
26.4 If the insurer determines that a claim was fraudulent, the insurer may terminate the insured person from
the policy with immediate effect. The insured person must refund to the insurer all incurred costs associated with the fraudulent claim within 15 working days from the date of request of reimbursement by the insurer.
26.5 If the insured person has a direct billing membership card, it is the policyholder’s responsibility to return the direct billing membership cards of the insured person and dependant(s) to the insurer if the insured person’s cover has been cancelled under the group policy or is not renewed under the group policy. The insurer will not be liable for any misuse by of such direct billing membership cards after the cancellation date.
26.6 The policyholder shall immediately notify the insurer of the loss of a direct billing membership card by any of its insured person(s) (including dependants).
26.7 The policyholder shall act as guarantor for the insured person. Any failure to discharge a liability by the insured person to the insurer shall be met by the policyholder acting as guarantor.
10. Miscellaneous
Article 28 – Right of Waiver
Waiver by the insurer of any breach of any term or condition of this insurance contract shall not prevent the subsequent enforcement of that term or condition and shall not be deemed to be a waiver of any subsequent breach.
Article 29 – Policy Administration
1. The policyholder undertakes that he/she will advise all eligible employees immediately if any reason this agreement should not be renewed or this agreement should be terminated in accordance with the provision of Article 26 above so that such eligible employees are made aware that all cover has ceased and that benefits will not be payable in respect of eligible employees or family members.
2. Actively at Work
Actively at Work shall mean the direct insured is employed by the policyholder on a full time permanent basis and the direct insured is performing all their regular duties according to their employment terms on a customary manner and on a full time basis.
If the direct insured is an employee, he/she needs to be Actively at Work on the day he/she becomes eligible to join the group plan. If insured person is not Actively at Work on the day he/she becomes eligible, his/her cover will only begin on the day he/she returns to work on an Actively at Work basis. The direct insured can only add his/her dependants when he/she returns to work.
The direct insured is considered NOT being Actively at Work if:
• The Insured person is working less than 80% of the required work hours or being paid less than 80% of the usual pay as stipulated in their employment terms
• The direct insured has a medical condition that necessitates absence from his/her usual work place for more than 60 days, with the exception of maternity/paternity leave as allowed by the local regulations.
3. As the purpose of the agreement is to provide cover for eligible employees and dependants, the policyholder undertakes to ensure that any revised policy wording or benefit schedule sent by the insurer to the policyholder, or any notice sent by the insurer to the policyholder relating to the cover, are issued without delay to all eligible employees.
4. The policyholder shall notify group members of any change in the terms and conditions of this group policy and any endorsements. The policyholder shall also notify group members of the changes in the terms and conditions of this group policy with those of any previously held policy.
5. The policyholder hereby indemnifies the insurer from and against any and all costs, losses and expenses incurred by the insurer consequent upon any failure by the policyholder to discharge its obligations under
this agreement. If the policyholder is not able to perform the responsibilities of any clause under Article 29 on the insurance contract that causes the insurer to be claimed, the policyholder should indemnify the insurer for all the losses, including but not limited to the dispute’s resolution fees, claim amount, legal fee and others.
6. The policyholder shall designate a responsible person (the policy administrator) to administer this agreement in accordance with its terms and any guidance issued by the insurer from time to time and shall notify the insurer in writing, of any change in the person designated.
7. Break in cover
Where there is a break in cover, for whatever reason, the insurer reserves the right to reapply exclusion 6.26 in respect of pre-existing medical conditions.
8. The policyholder shall remain responsible for ensuring its obligations under this agreement are fully discharged notwithstanding that all or any part of those obligations are delegated to an intermediary or agent who shall be deemed to be the agent of the company.
9. The policyholder shall advise the insurer immediately if it goes into liquidation or becomes bankrupt, or if an administrator or receiver or an administrative receiver is appointed in respect of all or any part of the business or assets of the company.
10. The policyholder must write and inform the insurer if the insured person changes their address or occupation.
11. General Conditions
Article 30 – General Conditions
1. The insurer reserves the right to revise or discontinue the group policy with effect from any renewal date.
2. The agreement can only be varied in writing. No variation will be admitted unless it is in writing and stampled by the insurer.
3. Any notice to be sent under this insurance contract must be in writing and be sent either by post or by facsimile machine and shall be considered to have been given if sent to the insurer at the registered address on the day after it was posted or, if sent by facsimile machine, at the time of dispatch.
4. The introduction of any change by the insurer in interpretation or practice in respect of any term or condition of the policyholder’s members’ documents shall not prevent the subsequent enforcement of that term or condition and shall not be deemed to form a precedent for any subsequent interpretation or practice.
5. In case of any inconsistency between Chinese version and English version, Chinese version shall prevail.
12. Definitions
1. Accident A sudden, unexpected, unforeseen and involuntary external event resulting in
identifiable physical injury occurring to an insured person whilst the insured person’s policy is in force.
2. Acute Condition A disease, illness or injury that is likely to respond quickly to treatment which aims to return the insured person to the state of health the insured was in immediately before suffering the disease, illness or injury, or which leads to the insured person’s
full recovery.
3. Act of Terrorism Any clandestine 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.
4. Age Based on the date of birth of the effective identity document to calculate the age. Started from the date of birth, it is age 0 and increased by 1 after 1 year. It is not counted if the period is less than 1 year.
5. Agreement An agreement the insurer has with each of the hospitals, day-patient units and scanning centres listed in the issued Now Health International Provider Network.
6. Alternative Therapies Refers to therapeutic and diagnostic treatment that exists outside the institutions where conventional medicine is taught. Such medicine includes, chiropractic treatment, chiropodists and podiatrists treatment, osteopathy, dietician, homeopathy and acupuncture as practised by approved therapists.
7. Apicoectomy Is a dental surgery performed to remove the root tip and the surrounding infected tissue of an abscessed tooth, when inflammation or infection persists in the bony area
around the end of a tooth after a root canal procedure. Apicoectomy is done to treat the following:
– Fractured tooth root
– A severely curved tooth root
– Teeth with caps or posts
– Cyst or infection which is untreatable with root canal therapy
– Root perforations
– Recurrent pain and infection
– Persistent symptoms that do not indicate problems from x-rays
– Calcification
– Damaged root surfaces and surrounding bone requiring surgery
8. Area of Cover: Default area of cover is Worldwide excluding U.S.A. This means the insurer provides Worldwide Cover for eligible treatment, but it does not cover any elective treatment in U.S.A. If the default area of cover is Worldwide excluding U.S.A, out of area of cover
means U.S.A. If the policyholder chooses “Mainland China Option” benefit, area of cover is Mainland China (excluding Hong Kong, Macau, Taiwan – same as below) and out of area of cover means area outside Mainland China.
9. Benefits Insurance cover provided by this policy and any extensions or restrictions shown in the certificate of insurance or in any endorsements (if applicable) and subject always to the insurer having received the premium due.
10. Benefit Schedule The table of benefits applicable to this policy showing the maximum benefits the insurer will pay.
11. Cancer A malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue.
12. Certificate of Insurance The certificate giving details of the policy, the insured persons, the period of cover, the underwriters, the date of entry, the level of cover and any endorsements that may apply.
13. Congenital Disorder A medical condition that is present at birth or is believed to have been present since birth, whether it is inherited or caused by environmental factors.
14. Co-Insurance Is the uninsured percentage of the costs, which the insured person must pay towards the cost of a claim.
15. Country of Nationality The country for which the insured person holds a passport.
16. Country of Residence The country in which the insured person habitually resides (usually for a period of no less than six months per period of cover) at the policy start date or entry date or at each subsequent renewal date.
SimpleCare Policy Wording (July 2023) | Definitions | 27
17. Chronic Condition A disease, illness or injury which has at least one of the following characteristics:
– It needs ongoing or long-term monitoring through consultations, examination, check-ups, drugs and dressings and/or tests
– It needs ongoing or long-term control or relief of symptoms
– It requires the insured person’s rehabilitation or for the insured person to be specially trained to cope with it
– It continues indefinitely
– It has no known cure
– It comes back or is likely to come back
18. Day-Patient A patient who is admitted to a hospital or day-patient unit because they need a period of medically supervised recovery but does not occupy a bed overnight.
19. Deductible An uninsured amount payable by an insured person in respect of in-patient,
day-patient and out-patient expenses incurred before any benefits are paid under the insurance policy, as specified in the insured person’s certificate of insurance. The deductible applies per insured person, per period of cover.
20. Dental Practitioner A person who is legally licensed to carry out this profession by the relevant licensing authority to practise dentistry in the country where the dental treatment is given.
21. Dependants One spouse or adult partner and/or unmarried children who are not more than
18 years old and residing with the insured person, or up to 28 years old if in full-time education (written proof may be required from the educational institute where they are enrolled), at the start date or any subsequent renewal date. The term partner shall mean husband, wife, civil partner or the person permanently living with the insured person in a similar relationship. All dependants must be named as insured persons in the certificate of insurance.
22. Diagnostic Tests Investigations, such as x-rays or blood tests, to find or to help to find the cause of the insured person’s symptoms.
23. Drugs and Dressings Essential prescription drugs, dressings and medicines administered by a medical
practitioner or specialist needed to relieve or cure a medical condition.
24. Eligible Those treatments and charges, which are covered by the insured person’s policy. In order to determine whether a treatment or charge is covered, all sections of the insured person’s policy should be read together, and are subject to all the terms (including payment of premium due), benefits and exclusions set out in this policy.
25. Entry Date The date shown on the certificate of insurance on which an insured person was included under this policy.
26. Evacuation or Moving the insured person to a hospital which has the necessary in-patient and
Repatriation Service day-patient repatriation service medical facilities either in the country where the insured person is taken ill or in another nearby country (evacuation) or bringing the insured person back to either the insured person’s principal country of nationality or the insured person’s principal country of residence (repatriation). The service includes any medically necessary treatment administered by the international assistance company appointed by the insurer while they are moving the insured person.
27. Excluded Countries Refers to the list of countries that We cannot offer You cover if You reside in any one of them. For details of Our list of Excluded Countries, please contact Our customer service team.
28. Expatriate Any persons living and/or working outside of the country for which they hold a passport. Usually for a period of more than 180 days per period of cover
29. Geographic Area The geographic area used to calculate the premium that will apply to the insured person based on the insured person’s principal country of residence at the start date or any subsequent renewal date of this policy.
30. High Cost Providers List The list of medical providers the insurer excludes from cover. The insurer does not cover any treatment costs incurred in any medical provider that is within the insurer’s High Cost Providers List. The insurer will update the High Cost Providers List on a periodic basis. For details of the insurer’s High Cost Providers List, the insured may contact the insurer’s customer service team.
31. Hospital Any establishment, which is licensed as a medical or surgical hospital under the laws of the country where it operates. The following establishments are not considered hospitals: rest and nursing homes, spas, cure-centres and health resorts.
32. Hospital Accommodation Refers to standard private or semi-private accommodation as indicated in the benefit schedule. Deluxe, executive rooms and VIP suites are not covered.
12. Definitions
33. In-Network An in-network medical provider is one contracted with the insured person’s policy to
Medical Provider provide services to policy members for specific pre-negotiated rates.
34. In-Patient A patient who is admitted to hospital and who occupies a bed overnight or longer, for medical reasons.
35. Insured Person The eligible employee and/or the dependants named on the certificate of insurance who are covered under this policy.
36. Insurer Asia-Pacific Property & Casualty Insurance Co., Ltd.
37. Medical Condition Any disease, injury, or illness, including psychiatric illness.
38. Medical Practitioner A person who has attained primary degrees in medicine or surgery following attendance at a WHO-recognised medical school and who is licensed to practise medicine by the relevant authority in the country where the treatment is given. By “recognised medical school” the insurer means a medical school, which is listed in the current World Directory of Medical Schools published by the WHO.
39. Medically Necessary Treatment which in the opinion of a qualified medical practitioner is appropriate and consistent with the diagnosis and which in accordance with generally accepted medical standards could not have been omitted without adversely affecting the insured person’s condition or the quality of medical care rendered. Such treatment must be required for reasons other than the comfort or convenience of the patient or medical practitioner and provided only for an appropriate duration of time. As used in this definition,
the term “appropriate” shall mean taking patient safety and cost effectiveness into consideration. When specifically applied to in-patient treatment, medically necessary also means that diagnosis cannot be made, or treatment cannot be safely and effectively provided on an out-patient basis.
40. New Born A baby who is within the first 16 weeks of its life following birth.
41. Now Health International Our published list of medical providers where the insurer/policy administrator has a
Provider Network direct billing provider network agreement.
42. Out of Network An out of network medical provider is one not contracted with the insured person’s
Medical Provider policy.
43. Out-Patient A patient who attends a hospital, consulting room, telemedicine appointment or out-patient clinic and is not admitted as a day-patient or an in-patient.
44. Out-Patient Direct Billing Our published list of medical providers where the insurer has a direct billing provider network.
45. Out-Patient An uninsured amount payable by an insured person in respect of out-patient expenses
Per Visit Excess before any benefits are paid under the insurance policy, as specified in the insured person’s certificate of insurance. Each visit refers to each consultation. The out-patient per visit excess applies per insured person, per out-patient consultation when you receive eligible out-patient treatment.
46. Period of Cover The period from 00:00 of the insurance policy start date to 23:59 of the insurance policy end date. It is usually for a period of 12 months.
47. Physiotherapist A practising physiotherapist who is registered and licensed to practise medicine in the country where treatment is provided.
48. Pre-Authorisation A process whereby an insured person seeks approval from the insurer prior to
undertaking any treatment or incurring costs. Such benefits requiring pre-authorisation from the insurer will denote pre-authorisation 🕿 in the benefit schedule.
49. Plan The contract between You and Us which set out terms and conditions of the cover provided. The full terms and conditions consist of the application form, Certificate of Insurance, Benefit Schedule and this members’ handbook.
50. Policyholder The person or company named as policyholder in the certificate of insurance.
51. Pregnancy Refers to the period of time, from the date of the first diagnosis, until delivery.
52. Primary Health Insurance If the insured person has more than one health insurance policy, this is the health insurance policy that pays claims first.
53. Primary Health Insurer The insurer of the primary health insurance plan.
54. Private Room Single occupancy accommodation in a private hospital. Deluxe, executive rooms and VIP suites are not covered.
55. Psychiatric Illness The mental or nervous disorder that meets the criteria for classification under an international classification system such as Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD). The disorder must be associated with present distress, or substantial impairment of the individual’s ability to function in a major life activity (e.g. employment). The aforementioned condition must be clinically significant and not merely an expected response to a particular event such as bereavement, relationship or academic problems and acculturation.
56. Qualified Nurse A nurse whose name is currently on any register or roll of nurses, maintained by any statutory nursing registration body within the country where treatment is provided.
57. Reasonable and The standard fee that would typically be made in respect of the insured person’s
Customary Charges customary charges treatment costs, in the country the insured person received treatment. The insurer may require such fees to be substantiated by an independent third party, such as a practising surgeon/physician/specialist or government health department/medical providers within the SimpleCare Provider Network..
58. Minimum Cash Value 1) Termination before the effective date of insurance: Minimum cash value = Premium
already paid by the policyholder.
2) Termination after the effective date of insurance (if the insurance premium is one-time payment):
Minimum Cash Value= Net premium ×(1-m/n), where m is the number of effective days on cover and n is the number of days in the insurance period. The outstanding hours less than one day will be regarded as one day.
Net premium = Premium already paid by the policyholder x (1 - Cost Ratio). Unless agreed, otherwise the cost ratio is 15%.
3) Termination after the waiting period of insurance (if the premium is paid in installments):
Minimum Cash Value= Net premium for the month ×(1-m/n), where m is the number of effective days on cover of that month and n is the number of days of that month. The outstanding hours less than one day will be regarded as one day.
Net premium for the month = Premium of that month already paid by the policyholder x (1 - Cost Ratio). Unless agreed, otherwise the cost ratio is 15%.
59. Rehabilitation Medically necessary treatment aimed at restoring independent activities of daily living and the normal form/and or function of an insured person following a medical condition.
60. Related Conditions A related condition is any disease, injury or illness including psychiatric illness that is caused by a pre-existing medical condition or results from the same underlying cause as a pre-existing medical condition.
61. Renewal Date The anniversary of the start date of the insurance policy.
62. Secondary Health If the insured person has more than one health insurance policy, Secondary Health
Insurance Insurance is the payer that pays claim after the Primary Health Insurance has paid its portion. If the insured person has more than one health insurance policy, this insurance policy will be the health insurance policy that pays last. If the insured person buys this insurance policy as a Secondary Health Insurance Policy, the insurer will only pay a claim if:
– the claim was submitted to the Primary Health Insurer but the claim was not paid/ fully settled due to ineligibility or the benefit limits have been exhausted under the Primary Health Insurance contract, and
– the unpaid claim amount is considered as eligible claim under this insurance policy.
The insured person will need to provide a copy of the certificate of insurance of the insured person’s Primary Health Insurance when the insured person applies for this insurance policy.
In any case, We will only pay the remaining balance of an Eligible claim amount that was not settled by the Primary Health Insurance.
63. Semi-Private Room Dual occupancy accommodation in a private hospital. Deluxe, executive rooms and VIP suites are not covered.
64. SimpleCare The insurer’s list of medical providers that is available to the insured person if the insured
Comprehensive Network person has extended the area of cover to Worldwide Excluding USA.
12. Definitions
65. Specialist A surgeon, anaesthetist or physician who has attained primary degrees in medicine or surgery following attendance at a WHO recognised medical school and who is licensed to practise medicine by the relevant authority in the country where the treatment is given, and is recognised as having a specialised qualification in the field of or expertise in, the treatment of the disease, illness or injury being treated. By “recognised medical school” the insurer means a medical school, which is listed in the current World Directory of Medical Schools published by the WHO.
66. Start Date The start date shown on the insured person’s certificate of insurance.
67. Surgical Procedure An operation requiring the incision of tissue or other invasive surgical intervention.
68. Terminal Illness Following the diagnosis that the condition is terminal and treatment can no longer be expected to cure the condition with death anticipated within 12 months of diagnosis.
69. Treatment Surgical or medical services (including Diagnostic Tests) that are needed to diagnose, relieve or cure a medical condition.
70. Vaccinations Refers to all basic immunisations and booster injections required under regulation of the country in which treatment is being given, any medically necessary travel vaccinations and malaria prophylaxis.
71. Waiting Period Is a period of time starting on the entry date of the insured person’s, during which
the insured person is not entitled to cover for particular benefits. The insured person’s benefit schedule will indicate which benefits are subject to waiting periods.
72. Group Legal organisation established not for purchasing insurance in China including
state owned organisation, colleagues and universities, enterprises and government- sponsored institutions, trade organisation, career union, etc.
73. Emergency A sudden, serious, and unforeseen acute medical condition or injury requiring immediate medical treatment, that without treatment commencing within 48 hours of the emergency event could result in death or serious impairment of bodily function.
74. WHO The World Health Organisation.
B. Benefit Schedule
This is for illustration purposes, please refer to the policy wording for full details.
Benefit | SimpleCare Amber |
Annual Maximum Group Policy Limit 24/7 helpline and assistance services available on all Plans | RMB 6,300,000 |
Geographical Area Default: | Worldwide Excluding USA |
Default Network: | SimpleCare Comprehensive Network |
1. Hospital Charges, Medical Practitioner and Specialist Fees: a) Charges for in-patient or day-patient treatment made by a hospital including charges for accommodation (ward/semi-private or private); diagnostic tests; operating theatre charges including surgeon and anaesthetist charges; and charges for nursing care by a qualified nurse; drugs and dressings prescribed by a medical practitioner or Specialist; and surgical appliances used by the medical practitioner during surgery. This includes pre and post-operative consultations while an in-patient or day-patient and includes charges for intensive care. b) Ancillary charges: Purchase and rental of crutches, canes, walking aids and self-propelled non-electronic wheelchairs within six months of an eligible medical condition which required in-patient or day-patient hospital treatment. | a) Full refund Pre-Authorisation 🕿 b) Up to RMB 9,450 per medical condition |
2. Diagnostic Procedures: Medically necessary diagnostic magnetic resonance imaging (MRI), positron emission tomography (PET) and computerised tomography (CT) scans received as an in-patient, day-patient or out-patient. 3. Renal Failure and Renal Dialysis: a) Treatment of renal failure, including renal dialysis on an in-patient basis. b) Treatment of renal failure, including renal dialysis on a day-patient or out-patient basis. 4. Organ Transplant: Treatment for and in relation to a human organ transplant of kidney, pancreas, liver, heart, lung, bone marrow or cornea, in respect of the insured person as a recipient. In circumstances where an organ transplant is required as a result of a congenital disorder, cover will be provided under Article 5, Benefit 7 – Congenital Disorder but excluded from Article 5, Benefit 4 – Organ Transplant. The insurer only pays for transplants carried out in internationally-accredited institutions by accredited surgeons and where the organ procurement is in accordance with WHO guidelines. Medical costs associated with the donor and the cost of the donor organ search are excluded from this Benefit. 5. Cancer Treatment: Treatment given for cancer received as an in-patient, day-patient or out-patient. Includes oncologist fees, surgery, radiotherapy and chemotherapy, alone or in combination, from the point of diagnosis. | Full Refund for in-patient pre and post-operative scans Pre-Authorisation for MRI, PET and CT 🕿 a) In-Patient pre and post-operative care up to six weeks full refund per Period of Cover b) Up to RMB 310,000 per period of cover Up to RMB 630,000 per period of cover Full refund |
Benefit | SimpleCare Amber |
6. New Born Baby Cover: In-patient treatment of premature birth (i.e. prior to age 37 weeks gestation) or an acute condition being suffered by a new born baby of an insured person which manifests itself within 30 days following birth. Provided that the new born baby is added to the group plan within 30 days of birth and premium paid. Cover for multiple births will be covered up to the same limits shown. In circumstances where the insurer requires details of the new born baby’s medical history before the baby is being added to the policy, the insurer reserves the right to apply particular restrictions to the cover the insurer will offer. Please refer to Article 3 – adding new born of this policy wording for details. | Up to RMB 157,500 per period of cover |
7. Congenital Disorders: In-patient treatment for a congenital disorder. In circumstances where a congenital disorder manifests itself in a new born baby within 30 days of birth, cover for such medical conditions will be provided under Article 5, Benefit 6 – New Born Baby Cover but excluded from Article 5, Benefit 7 – Congenital Disorders. 8. Parent Accommodation: The cost of one parent staying in hospital overnight with an insured person under 18 years old while the child is admitted as an in-patient for eligible treatment. 9. Hospital Accommodation for New Born Accompanying their Mother: Hospital accommodation costs relating to a new born baby (up to 16 weeks old) to accompany its mother (being an insured person) while she is receiving eligible treatment as an in-patient in a hospital. 10. Reconstructive Surgery: Reconstructive surgery required to restore natural function or appearance following an accident or following a surgical procedure for an eligible medical condition, which occurred after an insured person’s entry date or start date whichever is later. 11. Day-Patient and Out-Patient Surgery: Treatment costs for a surgical procedure performed in a surgery, hospital, day-care facility or out-patient department. 12. In-Patient Emergency Dental Treatment: The insurer will cover the actual incurred medical cost of emergency restorative dental treatment required to sound, natural teeth following an accident which necessitates the insured person’s admission to hospital for at least one night. The dental treatment must be received within 10 days of the accident. This benefit covers all costs incurred for treatment made necessary by an accidental injury caused by an extra-oral impact, when the following conditions apply: a) If the treatment involves replacing a crown, bridge facing, veneer or denture, the insurer will pay only the reasonable and customary cost of a replacement of similar type or quality b) If implants are clinically needed the insurer will pay only the cost which would have been incurred if equivalent bridgework was undertaken instead c) Damage to dentures providing they were being worn at the time of the injury. 13. Rehabilitation: When referred by a specialist as an integral part of treatment for a medical condition necessitating admission to a recognised rehabilitation unit of a hospital. Where the insured person was confined to a hospital as an in-patient for at least three consecutive days, and where a specialist confirms in writing that rehabilitation is required. Admission to a rehabilitation unit must be made within 14 days of discharge from hospital. Such treatment should be under the direct supervision and control of a specialist and would cover: a) Use of special treatment rooms b) Physical therapy fees c) Speech therapy fees d) Occupational therapy fees 14. Nursing Care at Home: Care given by qualified nurse in the insured person’s own home, which is immediately received subsequent to treatment as an in-patient or day-patient on the recommendation of medical practitioner or specialist. | Up to RMB 157,500 per period of cover Full refund Full refund Full refund Full refund Full refund Full Refund for eligible in-patient treatment only up to 30 days per medical condition Not Covered |
Benefit | SimpleCare Amber |
15. Emergency Ambulance Transportation: Emergency road ambulance transport costs to or between hospitals, or when considered medically necessary by a medical practitioner or specialist. | Full refund |
16. Evacuation and Repatriation: a) Evacuation Arrangements will be made to move an insured person who has a critical, life-threatening eligible medical condition to the nearest medical facility for the purpose of admission to hospital as an in-patient or day-patient. Reasonable expenses for: i) Transportation costs of an insured person in the event of emergency treatment and medically necessary transport and care not being readily available at the place of the incident. This includes an economy class airfare ticket for a locally-accompanying person who has travelled as an escort. ii) Reasonable local travel costs to and from medical appointments when treatment is being received as a day-patient. iii) Reasonable travel costs for a locally-accompanying person to travel to and from the hospital to visit the insured person following admission as an in-patient. iv) Reasonable costs for non-hospital accommodation only for immediate pre and post-hospital admission periods provided that the insured person is under the care of a specialist. Costs of evacuation do not extend to include any air-sea rescue or mountain rescue costs that are not incurred at recognised ski resorts or similar winter sports resorts. Our medical advisers will decide the most appropriate method of transportation for the evacuation and this benefit will not cover travel if it is against the advice of the insurer’s medical advisers or where the medical facility does not have appropriate facilities to treat the eligible medical condition. b) Repatriation An economy class airfare ticket to return the insured person and a locally-accompanying person who has travelled as an escort to the site of treatment to the insured person’s principal country of nationality or principal country of residence, as long as the journey is made within one month of completion of treatment. Such transportation cost is only eligible if there was a medical need for an initial evacuation that has taken place. Deductible would apply to medically necessary treatment required under this benefit. 17. Mortal Remains: In the event of death from an eligible medical condition, reasonable and customary charges for: a) Costs of transportation of body or ashes of an insured person to his/her country of nationality or country of residence, or b) Burial or cremation costs at the place of death in accordance with reasonable and customary practice. 18. Emergency Non-Elective Treatment outside Area of Cover: For planned trips up to 30 days of duration. Treatment by a medical practitioner or specialist starting within 24 hours of the emergency event, required as a result of an accident or the sudden beginning of a severe illness resulting in a medical condition that presents an immediate threat to the insured person’s health. 19. Hospital Cash Benefit: The insurer will cover the benefit payable for each night an insured person receives in-patient treatment and only if: a) the insured person is admitted for an elective in-patient treatment before midnight and the treatment is received within the public hospitals of the insured person’s country of residence; or b) this policy being the Secondary Health Insurance Policy. However, if the insured person has a RMB 63,000 or RMB 94,500 deductible policy, the insured person is not eligible for the benefit. Cover under this benefit is limited to a maximum of 30 nights per period of cover. For this Benefit exclusion 6.9 does not apply. | Pre-Authorisation 🕿 Combined limit up to RMB 630,000 a) Evacuation i) Full Refund ii) Full Refund iii) Full Refund iv) Up to RMB 1,200 per day. Up to RMB 47,000 per person, per evacuation Pre-Authorisation 🕿 b) Repatriation Full refund Pre-Authorisation 🕿 a) Full Refund b) Up to RMB 63,000 Accident: Full Refund for in-patient and day-patient treatment following accident Illness: In-patient and day-patient care up to RMB 157,500 per period of cover RMB 790 per night |
Benefit | SimpleCare Amber |
Annual Out-Patient Limit Applicable to Benefit 20 and 21 only, subject to Annual Maximum Policy Limit | Pre-operative consultation within 15 days from the admission and post hospitalisation consultation within 30 days following discharge from hospital Up to maximum RMB 4,700 per medical condition per period of cover. |
20. Out-Patient Charges: a) Medical Practitioner fees including consultations; Specialist fees; Diagnostic Tests; b) Teleconsultation (Virtual Doctor appointments via electronic means). Costs associated with Eligible Treatment will be paid in full where Treatment is received from Medical Providers listed in the SimpleCare Comprehensive Network. Treatment that is not received in the SimpleCare Comprehensive Network will pay Reasonable & Customary charges. No Out-Patient Co-Insurance or Out Patient visit Excess is applicable. c) Prescribed Drugs and Dressings. d) Vitamins and Minerals: Vitamins and Minerals as prescribed by a Medical Practitioner. Vitamins prescribed for a diagnosed deficiency will be paid as per the Out-Patient Benefit. Any pre-operative and post-hospitalisation consultations are payable under this Benefit. The insured does not have cover for costs relating to the maintenance of Chronic Conditions unless the insured is insured under SimpleCare Jade or SimpleCare Crystal, which the insurer will pay such eligible costs under Article 5, Benefit 20 – Out-Patient Charges. Please note: If claim receipts do not show a breakdown of the medical services rendered, We will only pay Eligible claims up to the Prescribed Drugs and Dressings limit. Annual Out-Patient Limit is applicable to Benefit 20 – Out-Patient Charges and Benefit 21 – Out-Patient Physiotherapy and Alternative Therapies only, subject to Annual Maximum Policy Limit. | a) and b) Pre-operative consultation within 15 days from the admission and post hospitalisation consultation within 30 days following discharge from hospital Up to maximum RMB 4,700 per medical condition per period of cover. c) Not covered d) Not covered |
21. Out-Patient Physiotherapy and Alternative Therapies The insurer will cover the actual incurred medical cost of: a) Physiotherapy by a Registered Physiotherapist. b) Complementary medicine and treatment by a therapist. This benefit extends to chiropractors, chiropodists and podiatrists, osteopaths, homeopaths, dietician and acupuncture treatment. c) Out-Patient Treatment for therapies administered by a recognised traditional Chinese Medical Practitioner or an Ayurvedic Medical Practitioner. You may choose 5 sessions for any combination of benefits in aggregate in a given period of cover for benefits a) and b) excluding dietician without the need of referral; any subsequent sessions need to be referred by a Medical Practitioner or Specialist. Annual Out-Patient Limit is applicable to Benefit 20 – Out-Patient Charges and Benefit 21 – Out-Patient Physiotherapy and Alternative Therapies only, subject to Annual Maximum Policy Limit. | Not Covered |
Benefit | SimpleCare Amber |
22. Menopause Hormone Replacement Therapy: The cost of Hormone Replacement Therapy when required to alleviate the symptoms of the early onset of menopause where onset and treatment commence below the age of 40 years. | Not Covered |
23. Out-Patient Psychiatric Illness: Out patient treatment administered by a registered psychologist and/or a registered psychiatrist, subject to 10 sessions and the cost limit under this section. For the first 5 sessions you may choose to visit a registered psychologist directly without the need for referral. However, any subsequent sessions with a registered psychologist will require referral and a treatment plan with a medical practitioner or specialist. 24. Dental Care: Fees of a registered Dental Practitioner carrying out dental Treatment in a dental clinic/surgery. This Benefit provides cover for the below dental Treatment: – Screening (including x-rays where necessary) – Preventive scaling, polishing, and sealing (once per year) – Fillings and extractions (non-surgical and surgical) – Root canal treatment – New or repair of crowns, dentures, in lays and bridges – Apicoectomy Dental implants and orthodontics Treatment are specifically excluded under this Benefit. No other Treatment is covered by this Benefit. Waiting period: Any expenses incurred within 180 days after the start date of the insured person’s policy are not payable. The insured person must have completed the waiting period of 180 days before the benefit is payable irrespective of whether the policyholder renews the insurance or not. A co-insurance of 20% applies. For this Benefit the deductible or out-patient per visit excess does not apply. | Not Covered Not Covered |
Additional Options | SimpleCare Amber |
25. Mainland China option: | Optional Emergency non-elective treatment outside of Mainland China: illness limit up to RMB 150,000 per period of cover |
The insurer will cover the medical costs associated with all eligible in-patient, day-patient, and out-patient treatment restricted to Mainland China and will be subject to the standard policy limits. | |
Emergency non-elective treatment outside of Mainland China: | |
For planned trips up to 30 days of duration. Treatment by a medical practitioner or specialist starting within 24 hours of the emergency event, required as a result of an accident or the sudden beginning of a severe illness resulting in a medical condition that presents an immediate threat to the insured person’s health. | |
Full refund for accident requiring in-patient and day-patient care. | |
Illness: In-patient and day-patient care up to the sub-limit listed in various plans per period of cover | |
26. Hospital Room Restriction – Hospital Room & Board Limit RMB 800: | |
As described in Article 5 Benefit 1 a) on the insurance contract, but with a restriction to limit the hospital accommodation for hospital admission in Mainland China up to RMB 800 per day for any charge for eligible in-patient or day-patient treatment made by the hospital and by any medical practitioner, should the in-patient or day-patient be received in any in-patient/day-patient facility in Mainland China as pre-defined and advised by the insurer. | Optional In-patient or day-patient treatment received in any in-patient or day-patient facility in Mainland China up to RMB 800 per day |
27. High Cost Provider Restriction: | |
The insurer will not cover the medical costs associated with eligible in-patient, day-patient or out-patient treatment made by the hospital, and by any medical professional, should the in-patient, day-patient or out-patient treatment be received in any high cost in-patient/day-patient facility in Mainland China as pre-defined and advised by the insurer. | Optional |
28. In-Patient Co-Insurance at Private Hospital: | |
The insurer will cover the actual medical costs associated with the benefits for eligible in-patient or day-patient treatment at a private hospital subject to 20% co-insurance. | Optional |
20% co-insurance | |
29. Annual Maximum Policy Limit RMB 1,000,000: | |
During the insured period of this contract, in case of any medical activities taken in this insurance contract, the insurer shall pay the insurance benefits (i.e. specific benefit will not exceed its corresponding benefit limit and the sum of the benefits paid will not exceed the annual maximum policy limit of RMB 1,000,000. | Optional |
30. Co-Insurance Out-Patient Treatment: | |
A 20% co-insurance will apply on all eligible out-patient treatment. | |
Please note co-insurance does not apply to cancer treatment, organ transplant or renal failure and renal dialysis. This option is not available for policies with deductibles of RMB 6,300 or higher. Should the plan includes maternity, dental care or wellness and vaccinations benefits, any applicable co-insurance will be detailed in insured person’s benefit schedule. | Not Covered |
31. Out-Patient Per Visit Excess: | |
An RMB 150 out-patient per visit excess will apply when the insured person receives eligible out-patient treatment. The out-patient per visit excess would apply to both Article 5, Benefits 20 – Out-Patient Charges and Benefits 21 – Out-Patient Physiotherapy and Alternative Therapies Benefits. | Not Covered |
This option is not available for Group Plans with deductibles of RMB 6,300 or higher. | |
32. Removal of Drugs and Dressings Limit: | |
By selecting this option, cover for Prescribed Drugs and Dressings under Benefit 20 c) will be Full Refund, subject to annual Out-Patient limit. | |
For Compulsory Group Plans 3+ employees | Not Covered |
Additional Options | SimpleCare Amber |
33. Wellness and Vaccinations – Option 1: Compulsory group policies 3+ employees a) Wellness: this benefit is payable as a contribution towards the cost of routine health checks including cancer screening, BRCA I & II Test (where a direct family history exists), bone densitometry (once every five years for women aged 50+), cardiovascular examination, neurological examinations, vital signs (e.g. blood pressure, body mass index, urinalysis, cholesterol), well child test (Up to age of 5 Years), and/or b) Vaccinations: Costs of drugs and consultations to administer all medically necessary basic immunisation and booster injections and any medically necessary travel vaccinations and malaria prophylaxis. For this Benefit exclusion 6.9 does not apply. | a) Not covered b) Not covered |
34. Wellness and Vaccinations – Option 2: Compulsory group policies 3+ employees a) Wellness: this benefit is payable as a contribution towards the cost of routine health checks including cancer screening, BRCA I & II Test (where a direct family history exists), bone densitometry (once every five years for women aged 50+), cardiovascular examination, neurological examinations, vital signs (e.g. blood pressure, body mass index, urinalysis, cholesterol), well child test (Up to age of 5 Years), and/or b) Vaccinations: Costs of drugs and consultations to administer all medically necessary basic immunisation and booster injections and any medically necessary travel vaccinations and malaria prophylaxis. For this Benefit exclusion 6.9 does not apply. 35. Maternity – Option 1: a) Medically Necessary costs incurred during Pregnancy and childbirth: childbirth costs, including pre and post-natal check-ups for up to six weeks following birth, scans and delivery costs for a natural birth or voluntary/Emergency caesarean section. Paediatrician costs for the first examination/check-up of a New Born baby, if the examination is made within 24 hours of delivery and Well-baby examinations up to the child’s second birthday and as recommended by a Medical Practitioner or Specialist. This includes physical examinations, measurements, sensory screening, neuropsychiatric evaluation, development screening, as well as hereditary and metabolic screening, immunisations, urine analysis, tuberculin tests and hematocrit, haemoglobin and other blood tests, including tests to screen for sickle haemoglobinopathy. Please note We will pay for the above Well-baby examinations costs only if We have paid the delivery cost of the baby under this Group Plan, provided the baby is being added into the Group Plan as an Insured Person. b) For In-Patient Treatment of an Eligible Medical Condition which arises during the antenatal stages of Pregnancy or an Eligible Medical Condition which arises during childbirth, the insurer would only allow Treatment of the following as an Eligible Medical Condition under this Benefit b): – Ectopic pregnancy (where the foetus is growing outside the womb) – Hydatidiform mole (abnormal cell growth in the womb) – Retained placenta (afterbirth retained in the womb) – Placenta praevia – Eclampsia (a coma or seizure during pregnancy and following pre-eclampsia) – Diabetes (If the insured person has exclusions because of the insured person’s past medical history which relate to diabetes, then the insured person will not be covered for any treatment for diabetes during pregnancy) – Post partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth) – Miscarriage requiring immediate surgical treatment This benefit b) does not provide any cover for voluntary/ Emergency caesarean section procedures or ‘failure to progress in labour’ unless for one of the above stated Eligible Medical Conditions. Waiting period: Any expenses incurred within 180 days after the start date of the insured person’s policy are not payable. For the expenses incurred after the 180th day to one year after the policy takes effect, this benefit has a 95% co-insurance. The insured person must have completed the waiting period of 180 days before the benefit is payable irrespective of whether the policyholder renews the insurance or not. Please note, the insurer does not pay for parenting or other teaching classes as these are a matter of personal choice. For Compulsory Group Plans 10+ employees For this Benefit exclusion 6.27 does not apply. Deductible would apply to this benefit. | a) Not covered b) Not covered a) Not covered b) Not covered |
Additional Options | SimpleCare Amber |
36. Maternity – Option 2: a) Medically Necessary costs incurred during Pregnancy and childbirth: childbirth costs, including pre and post-natal check-ups for up to six weeks following birth, scans and delivery costs for a natural birth or voluntary/Emergency caesarean section. Paediatrician costs for the first examination/check-up of a New Born baby, if the examination is made within 24 hours of delivery and Well-baby examinations up to the child’s second birthday and as recommended by a Medical Practitioner or Specialist. This includes physical examinations, measurements, sensory screening, neuropsychiatric evaluation, development screening, as well as hereditary and metabolic screening, immunisations, urine analysis, tuberculin tests and hematocrit, haemoglobin and other blood tests, including tests to screen for sickle haemoglobinopath. Please note We will pay for the above Well-baby examinations costs only if We have paid the delivery cost of the baby under this Group Plan, provided the baby is being added into the Group Plan as an Insured Person. b) For In-Patient Treatment of an Eligible Medical Condition which arises during the antenatal stages of Pregnancy or an Eligible Medical Condition which arises during childbirth, the insurer would only allow Treatment of the following as an Eligible Medical Condition under this Benefit b): – Ectopic pregnancy (where the foetus is growing outside the womb) – Hydatidiform mole (abnormal cell growth in the womb) – Retained placenta (afterbirth retained in the womb) – Placenta praevia – Eclampsia (a coma or seizure during pregnancy and following pre-eclampsia) – Diabetes (If the insured person has exclusions because of the insured person’s past medical history which relate to diabetes, then the insured person will not be covered for any treatment for diabetes during pregnancy) – Post partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth) – Miscarriage requiring immediate surgical treatment This benefit b) does not provide any cover for voluntary/ Emergency caesarean section procedures or ‘failure to progress in labour’ unless for one of the above stated Eligible Medical Conditions. Waiting period: Any expenses incurred within 180 days after the start date of the insured person’s policy are not payable. For the expenses incurred after the 180th day to one year after the policy takes effect, this benefit has a 95% co-insurance. The insured person must have completed the waiting period of 180 days before the benefit is payable irrespective of whether the policyholder renews the insurance or not. Please note, the insurer does not pay for parenting or other teaching classes as these are a matter of personal choice. For Compulsory Group Plans 10+ employees For this Benefit exclusion 6.27 does not apply. Deductible would apply to this benefit. | a) Not covered b) Not covered |
Underwriting Options | SimpleCare Amber |
37. Capped Cover for Declared Pre-existing Medical Conditions: | |
For Compulsory Group Plans 5 to 19 employees. This underwriting option provides limited cover for any pre-existing Medical Conditions that are declared and accepted by Us. Waiting period: Any expenses incurred within 180 days after the start date of the insured Person’s policy are not payable. The insured person must have completed the waiting period of 180 days before the benefit is payable irrespective of whether the policyholder renews the insurance or not. | Optional For Compulsory Group Plans 5 to 19 employees After Waiting Period: RMB 12,600 per declared pre-existing Medical Condition |
After Waiting Period and until the Group Plan renews: RMB 25,200 per declared pre-existing Medical Condition, per Period of Cover | |
38. Medical History Disregarded: Compulsory group policies 10+ employees | Optional |
Deductible Options | SimpleCare Amber |
Standard Deductible | RMB 3,150 |
Optional Deductible | Nil |
Please note: RMB 63,000 or RMB 94,500 deductible is only available if the policyholder is covered by more than one health insurance policy. The policyholder can only select such deductible options if the policyholder buys this policy as | RMB 950 RMB 1,570 |
a Secondary Health Insurance Policy. The policyholder will be required to provide details of the policyholder’s | RMB 6,300 |
Primary Health Insurance when the policyholder applies for cover under this policy. | RMB 15,700 |
RMB 31,500 | |
RMB 63,000 | |
RMB 94,500 |
This is for illustration purposes, please refer to the policy wording for full details.
Benefit | SimpleCare Jade |
Annual Maximum Group Policy Limit 24/7 helpline and assistance services available on all Plans | RMB 9,450,000 |
Geographical Area Default: | Worldwide Excluding USA |
Default Network: | SimpleCare Comprehensive Network |
1. Hospital Charges, Medical Practitioner and Specialist Fees: a) Charges for in-patient or day-patient treatment made by a hospital including charges for accommodation (ward/semi-private or private); diagnostic tests; operating theatre charges including surgeon and anaesthetist charges; and charges for nursing care by a qualified nurse; drugs and dressings prescribed by a medical practitioner or Specialist; and surgical appliances used by the medical practitioner during surgery. This includes pre and post-operative consultations while an in-patient or day-patient and includes charges for intensive care. b) Ancillary charges: Purchase and rental of crutches, canes, walking aids and self-propelled non-electronic wheelchairs within six months of an eligible medical condition which required in-patient or day-patient hospital treatment. | a) Full refund Pre-Authorisation 🕿 b) Up to RMB 9,450 per medical condition |
2. Diagnostic Procedures: Medically necessary diagnostic magnetic resonance imaging (MRI), positron emission tomography (PET) and computerised tomography (CT) scans received as an in-patient, day-patient or out-patient. 3. Renal Failure and Renal Dialysis: a) Treatment of renal failure, including renal dialysis on an in-patient basis. b) Treatment of renal failure, including renal dialysis on a day-patient or out-patient basis. 4. Organ Transplant: Treatment for and in relation to a human organ transplant of kidney, pancreas, liver, heart, lung, bone marrow or cornea, in respect of the insured person as a recipient. In circumstances where an organ transplant is required as a result of a congenital disorder, cover will be provided under Article 5, Benefit 7 – Congenital Disorder but excluded from Article 5, Benefit 4 – Organ Transplant. The insurer only pays for transplants carried out in internationally-accredited institutions by accredited surgeons and where the organ procurement is in accordance with WHO guidelines. Medical costs associated with the donor and the cost of the donor organ search are excluded from this Benefit. 5. Cancer Treatment: Treatment given for cancer received as an in-patient, day-patient or out-patient. Includes oncologist fees, surgery, radiotherapy and chemotherapy, alone or in combination, from the point of diagnosis. | Full Refund Pre-Authorisation for MRI, PET and CT 🕿 a) Up to six weeks full refund per period of cover b) Up to RMB 310,000 per period of cover Up to RMB 945,000 per period of cover Full refund |
Benefit | SimpleCare Jade |
6. New Born Baby Cover: In-patient treatment of premature birth (i.e. prior to age 37 weeks gestation) or an acute condition being suffered by a new born baby of an insured person which manifests itself within 30 days following birth. Provided that the new born baby is added to the group plan within 30 days of birth and premium paid. Cover for multiple births will be covered up to the same limits shown. In circumstances where the insurer requires details of the new born baby’s medical history before the baby is being added to the policy, the insurer reserves the right to apply particular restrictions to the cover the insurer will offer. Please refer to Article 3 – adding new born of this policy wording for details. | Up to RMB 220,500 per period of cover |
7. Congenital Disorders: In-patient treatment for a congenital disorder. In circumstances where a congenital disorder manifests itself in a new born baby within 30 days of birth, cover for such medical conditions will be provided under Article 5, Benefit 6 – New Born Baby Cover but excluded from Article 5, Benefit 7 – Congenital Disorders. 8. Parent Accommodation: The cost of one parent staying in hospital overnight with an insured person under 18 years old while the child is admitted as an in-patient for eligible treatment. 9. Hospital Accommodation for New Born Accompanying their Mother: Hospital accommodation costs relating to a new born baby (up to 16 weeks old) to accompany its mother (being an insured person) while she is receiving eligible treatment as an in-patient in a hospital. 10. Reconstructive Surgery: Reconstructive surgery required to restore natural function or appearance following an accident or following a surgical procedure for an eligible medical condition, which occurred after an insured person’s entry date or start date whichever is later. 11. Day-Patient and Out-Patient Surgery: Treatment costs for a surgical procedure performed in a surgery, hospital, day-care facility or out-patient department. 12. In-Patient Emergency Dental Treatment: The insurer will cover the actual incurred medical cost of emergency restorative dental treatment required to sound, natural teeth following an accident which necessitates the insured person’s admission to hospital for at least one night. The dental treatment must be received within 10 days of the accident. This benefit covers all costs incurred for treatment made necessary by an accidental injury caused by an extra-oral impact, when the following conditions apply: a) If the treatment involves replacing a crown, bridge facing, veneer or denture, the insurer will pay only the reasonable and customary cost of a replacement of similar type or quality b) If implants are clinically needed the insurer will pay only the cost which would have been incurred if equivalent bridgework was undertaken instead c) Damage to dentures providing they were being worn at the time of the injury. 13. Rehabilitation: When referred by a specialist as an integral part of treatment for a medical condition necessitating admission to a recognised rehabilitation unit of a hospital. Where the insured person was confined to a hospital as an in-patient for at least three consecutive days, and where a specialist confirms in writing that rehabilitation is required. Admission to a rehabilitation unit must be made within 14 days of discharge from hospital. Such treatment should be under the direct supervision and control of a specialist and would cover: a) Use of special treatment rooms b) Physical therapy fees c) Speech therapy fees d) Occupational therapy fees 14. Nursing Care at Home: Care given by qualified nurse in the insured person’s own home, which is immediately received subsequent to treatment as an in-patient or day-patient on the recommendation of medical practitioner or specialist. | Up to RMB 220,500 per period of cover Full refund Full refund Full refund Full refund Full refund Full Refund up to 90 days per medical condition Full Refund up to 30 days per medical condition Pre-Authorisation 🕿 |
Benefit | SimpleCare Jade |
15. Emergency Ambulance Transportation: Emergency road ambulance transport costs to or between hospitals, or when considered medically necessary by a medical practitioner or specialist. | Full refund |
16. Evacuation and Repatriation: a) Evacuation Arrangements will be made to move an insured person who has a critical, life-threatening eligible medical condition to the nearest medical facility for the purpose of admission to hospital as an in-patient or day-patient. Reasonable expenses for: i) Transportation costs of an insured person in the event of emergency treatment and medically necessary transport and care not being readily available at the place of the incident. This includes an economy class airfare ticket for a locally-accompanying person who has travelled as an escort. ii) Reasonable local travel costs to and from medical appointments when treatment is being received as a day-patient. iii) Reasonable travel costs for a locally-accompanying person to travel to and from the hospital to visit the insured person following admission as an in-patient. iv) Reasonable costs for non-hospital accommodation only for immediate pre and post-hospital admission periods provided that the insured person is under the care of a specialist. Costs of evacuation do not extend to include any air-sea rescue or mountain rescue costs that are not incurred at recognised ski resorts or similar winter sports resorts. Our medical advisers will decide the most appropriate method of transportation for the evacuation and this benefit will not cover travel if it is against the advice of the insurer’s medical advisers or where the medical facility does not have appropriate facilities to treat the eligible medical condition. b) Repatriation An economy class airfare ticket to return the insured person and a locally-accompanying person who has travelled as an escort to the site of treatment to the insured person’s principal country of nationality or principal country of residence, as long as the journey is made within one month of completion of treatment. Such transportation cost is only eligible if there was a medical need for an initial evacuation that has taken place. Deductible would apply to medically necessary treatment required under this benefit. 17. Mortal Remains: In the event of death from an eligible medical condition, reasonable and customary charges for: a) Costs of transportation of body or ashes of an insured person to his/her country of nationality or country of residence, or b) Burial or cremation costs at the place of death in accordance with reasonable and customary practice. 18. Emergency Non-Elective Treatment outside Area of Cover: For planned trips up to 30 days of duration. Treatment by a medical practitioner or specialist starting within 24 hours of the emergency event, required as a result of an accident or the sudden beginning of a severe illness resulting in a medical condition that presents an immediate threat to the insured person’s health. 19. Hospital Cash Benefit: The insurer will cover the benefit payable for each night an insured person receives in-patient treatment and only if: a) the insured person is admitted for an elective in-patient treatment before midnight and the treatment is received within the public hospitals of the insured person’s country of residence; or b) this policy being the Secondary Health Insurance Policy. However, if the insured person has a RMB 63,000 or RMB 94,500 deductible policy, the insured person is not eligible for the benefit. Cover under this benefit is limited to a maximum of 30 nights per period of cover. For this Benefit exclusion 6.9 does not apply. | Pre-Authorisation 🕿 Combined limit up to RMB 630,000 a) Evacuation i) Full Refund ii) Full Refund iii) Full Refund iv) Up to RMB 1,200 per day. Up to RMB 47,000 per person, per evacuation Pre-Authorisation 🕿 b) Repatriation Full refund Pre-Authorisation 🕿 a) Full Refund b) Up to RMB 63,000 Accident: Full Refund for in-patient and day-patient treatment following accident Illness: In-patient and day-patient care up to RMB 220,500 per period of cover RMB 1,575 per night |
Benefit | SimpleCare Jade |
Annual Out-Patient Limit Applicable to Benefit 20 and 21 only, subject to Annual Maximum Policy Limit | RMB 6,300 |
20. Out-Patient Charges: a) Medical Practitioner fees including consultations; Specialist fees; Diagnostic Tests; b) Teleconsultation (Virtual Doctor appointments via electronic means). Costs associated with Eligible Treatment will be paid in full where Treatment is received from Medical Providers listed in the SimpleCare Comprehensive Network. Treatment that is not received in the SimpleCare Comprehensive Network will pay Reasonable & Customary charges. c) Prescribed Drugs and Dressings. d) Vitamins and Minerals: Vitamins and Minerals as prescribed by a Medical Practitioner. Vitamins prescribed for a diagnosed deficiency will be paid as per the Out-Patient Benefit. Any pre-operative and post-hospitalisation consultations are payable under this Benefit. The insured does not have cover for costs relating to the maintenance of Chronic Conditions unless the insured is insured under SimpleCare Jade or SimpleCare Crystal, which the insurer will pay such eligible costs under Article 5, Benefit 20 – Out-Patient Charges. Please note: If claim receipts do not show a breakdown of the medical services rendered, We will only pay Eligible claims up to the Prescribed Drugs and Dressings limit. Annual Out-Patient Limit is applicable to Benefit 20 – Out-Patient Charges and Benefit 21 – Out-Patient Physiotherapy and Alternative Therapies only, subject to Annual Maximum Policy Limit. | a) and b) Full refund subject to Annual Out-Patient Limit c) Full refund subject to Annual Out-Patient Limit d) Up to RMB 940 per period of cover a), b), c) and d) subject to Annual Out-Patient Limit |
21. Out-Patient Physiotherapy and Alternative Therapies The insurer will cover the actual incurred medical cost of: a) Physiotherapy by a Registered Physiotherapist. b) Complementary medicine and treatment by a therapist. This benefit extends to chiropractors, chiropodists and podiatrists, osteopaths, homeopaths, dietician and acupuncture treatment. c) Out-Patient Treatment for therapies administered by a recognised traditional Chinese Medical Practitioner or an Ayurvedic Medical Practitioner. You may choose 5 sessions for any combination of benefits in aggregate in a given period of cover for benefits a) and b) excluding dietician without the need of referral; any subsequent sessions need to be referred by a Medical Practitioner or Specialist. Annual Out-Patient Limit is applicable to Benefit 20 – Out-Patient Charges and Benefit 21 – Out-Patient Physiotherapy and Alternative Therapies only, subject to Annual Maximum Policy Limit. | a) Up to RMB 380 per visit b) Up to RMB 380 per visit c) Up to RMB 190 per visit Combined up to 10 visits for a), b) and c) per period of cover, subject to Annual Out-Patient Limit |