GREAT EASTERN LIFE SUPREMEHEALTH PLAN POLICY VERSION 08/13 (AS CHARGED)

Transcription

1 GREAT EASTERN LIFE SUPREMEHEALTH PLAN POLICY VERSION 08/13 (AS CHARGED) In THIS POLICY,"THE COMPANY" is THE GREAT EASTERN LIFE ASSURANCE COMPANY LIMITED and "THE POLICYHOLDER" is the Policyholder named in Schedule A. "LIFE ASSURED" refers to any person named as the Life Assured in Schedule A or in an endorsement on this Policy. SCHEDULE A defines the scope of the insurance under this Policy, including the Plan Type for the Life Assured, and all clauses and conditions must be read in conjunction with this Schedule. Schedule A may be varied by endorsements on this Policy. From time to time, the Company may issue a fresh Schedule A which consolidates all variations made since the last Schedule A was issued. Upon issue, the new Schedule A will take effect from the stated Effective Date and all previous Schedules A will be void from that date. THIS Policy; the written Proposal and Declarations (which form the basis of this Contract); (c) all subsequent written notices given by the Company to the Policyholder; and (d) all subsequent written statements given by the Policyholder to the Company, will make up the whole of the Contract of Insurance between the Company and the Policyholder. NOW, THIS POLICY confirms that, if at any time during a Period of Insurance, the Life Assured incurs any Eligible Expenses as described in this Policy as a result of Injury, illness or disease THEN the Company will reimburse the Hospital (as defined in this Policy), medical clinic or other medical establishment using the Electronic Claims Filing System, the Policyholder, or the Policyholder's legal personal representative(s), the benefits as stated in this Policy. THIS SUPREMEHEALTH PLAN Insurance is subject to the clauses contained in this Policy and in endorsements, if any, attached to this Policy. No change in or endorsement on this Policy is valid unless approved by a duly authorised representative of the Company. DIRECTOR DIRECTOR

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3 GREAT EASTERN LIFE SUPREMEHEALTH PLAN POLICY VERSION 08/13 (AS CHARGED) CONTENTS DESCRIPTION PAGE DESCRIPTION PAGE Schedule A and Endorsements (if any) Attachments Schedule B 2 Clauses and Conditions 1 POLICY DEFINITIONS Special Definitions 1.2 Expenses 1.3 Psychiatric Treatment 2 LIFE ASSURED JOINTLY INSURED 9 UNDER MEDISHIELD 3 LIMITS ON ELIGIBLE EXPENSES 10 4 BENEFITS Subject to Clauses and Conditions 4.2 Reimbursement of Eligible Expenses 4.3 Benefit Computation 4.4 Benefit Limits 4.5 Indemnity and Last Payer Status 5 EXCLUSIONS General Exclusions 5.2 Pre-existing Conditions 5.3 Expenses Falling under Exclusion 6 TERRITORIAL FACTORS Overseas Emergency Medical Treatment 6.2 Currency Exchange 7 TERMINATION Termination on Renewal Date 7.2 Death of Policyholder or Life Assured 7.3 Cancellation By Policyholder 7.4 Not Citizen or Permanent Resident : Residence Overseas 7.5 Life Assured Insured under Another Shield Plan 7.6 No Benefits Payable after Termination of Insurance 8 RENEWAL When No Renewal Allowed 8.2 Renewal Upon Payment of Premium 8.3 Grace Period 8.4 Rate of Premium 8.5 Company May Amend Clauses and Conditions and Premium Rates 8.6 Upgrading/Downgrading of Plan Type 9 REINSTATEMENT OF POLICY Clauses and Conditions 9.2 Reinstatement Premium Rate 9.3 When No Reinstatement Allowed 10 CLAIM Notification 10.2 Submission and Documentation 10.3 Medical Examiner's Certificate 10.4 Medical Examination 10.5 Expiration of Liability 11 POLICY - WHEN VOID Misrepresentation or Non-disclosure of Material Facts 11.2 Refund of Premium 11.3 Fraudulent Claim 12 OTHER CONDITIONS Form of Notices 12.2 Alteration of Policy 12.3 Errors of Age 12.4 Absolute Owner 12.5 Law of the Republic of Singapore 12.6 Exclusion of the Contracts (Rights of Third Parties) Act 2001 The table of contents, headings and sub-heading in this Policy are inserted merely for convenience of reference and will be ignored in the interpretation of the clauses and conditions contained in this Policy. 1 SupremeHealth Plan Policy Version 08/13

4 GREAT EASTERN LIFE SUPREMEHEALTH PLAN (SHP) SCHEDULE B: BENEFIT LIMITS (inclusive of MediShield Basic Limits) LIMITS ON ELIGIBLE EXPENSES (All Amounts in S$) Plan Type P Plus A Plus B Plus Hospital/Ward Class Entitlement to As Charged Reimbursement Private Hospitals Restructured Hospitals, Class A Wards Restructured Hospitals, Class B1 Wards EXPENSE ITEM AMOUNT LIMIT AMOUNT LIMIT AMOUNT LIMIT 1. INPATIENT BENEFITS A. HOSPITALISATION AND SURGERY BENEFITS Room & Board As Charged (1) As Charged (1) As Charged (1) Intensive Care Unit (ICU) As Charged (1) As Charged (1) As Charged (1) Short-stay Ward As Charged (1) As Charged (1) As Charged (1) Miscellaneous Hospital Services As Charged (1) As Charged (1) As Charged (1) Daily In-Hospital Physician s Visit As Charged (1) As Charged (1) As Charged (1) Surgery As Charged (1) As Charged (1) As Charged (1) Surgical Implants / Approved Medical Consumables As Charged (1) As Charged (1) As Charged (1) Gamma Knife As Charged (1) As Charged (1) As Charged (1) Confinement in Community Hospital $500 per day $450 per day $400 per day B. ADDITIONAL INPATIENT BENEFITS Pregnancy and Childbirth Complications As Charged (1) As Charged (1) As Charged (1) Breast Reconstruction after Mastectomy As Charged (1) As Charged (1) As Charged (1) Accidental Dental Treatment As Charged (1) As Charged (1) As Charged (1) Stem Cell Transplant As Charged (1) As Charged (1) As Charged (1) Human Immunodeficiency Virus Due to Blood Transfusion and Occupationally Acquired HIV As Charged (1) As Charged (1) As Charged (1) $20,000 per Period of Insurance $15,000 per Period of Insurance $10,000 per Period of Insurance Congenital Abnormalities (Within (and including) 730 days from the Last Policy Effective Date) (Within (and including) 730 days from the Last Policy Effective Date) (Within (and including) 730 days from the Last Policy Effective Date) As Charged (1) (After 730 days from the Last Policy Effective Date) As Charged (1) (After 730 days from the Last Policy Effective Date) As Charged (1) (After 730 days from the Last Policy Effective Date) Living Organ Donor Transplant (Kidney/Liver) $50,000 per Transplant $30,000 per Transplant $20,000 per Transplant Psychiatric Treatment (including Pre & Post Hospital Benefits) C. PRE & POST HOSPITAL BENEFITS Pre-Hospital Specialist s Consultation (within 120 days before Hospitalisation) Examination and Laboratory Tests (During Hospitalisation and within 120 days before Hospitalisation) Post-Hospital Follow - up Treatment (within 120 days from Hospital discharge) 2. OUTPATIENT BENEFITS $8,000 per Period of Insurance $6,000 per Period of Insurance $2,000 per Period of Insurance As Charged (1) As Charged (1) As Charged (1) As Charged (1) As Charged (1) As Charged (1) As Charged (1) As Charged (1) As Charged (1) Erythropoietin As Charged (1) As Charged (1) As Charged (1) Immunosuppressant drugs prescribed for treatment of organ transplants: 1. Cyclosporin As Charged (1) As Charged (1) As Charged (1) 2. Tacrolimus 3. Other Immunosuppressant drugs 2 SupremeHealth Plan Policy Version 08/13

5 Kidney Dialysis Treatment As Charged (1) As Charged (1) As Charged (1) Cancer Treatment: 1. Radiotherapy 2. Chemotherapy As Charged (1) As Charged (1) As Charged (1) 3. Immunotherapy 4. Stereotactic Radiotherapy 3. FINAL EXPENSES BENEFIT $ 7,000 $ 6,000 $ 3, OTHER BENEFITS Emergency Medical Treatment outside As Charged (1) Singapore (2) (But limited to Singapore private Hospital charges) (1) (2) As Charged (1) (But limited to Singapore Restructured Hospitals, Class A ward charges) As Charged (1) (But limited to Singapore Restructured Hospitals, Class B1 ward charges) As Charged means all Eligible Expenses incurred by the Life Assured in the Hospital and ward Class of the Life Assured s entitlement under the Plan Type insured Covers all Eligible Expenses if the Life Assured requires medical or surgical treatment as a result of an Emergency while outside Singapore up to limits stated above. PRO-RATION FACTORS (3) P Plus A Plus B Plus Pro-ration Factor to apply to private Hospital charges NA 70% 50% Pro-ration Factor to apply to Restructured (4) Hospital, Class A ward charges NA NA 80% (3) Please refer to Clause and Clause (4) Does not apply to the Expenses incurred in a Restructured Hospital for the following treatments provided to the Life Assured on an outpatient basis: Kidney Dialysis Treatment, Cancer Treatment, Erythropoietin and Immunosuppressant drugs prescribed for treatment of organ transplants DEDUCTIBLE (5) P Plus A Plus B Plus Per Period of Insurance (Up to and including age 85 (6) years next birthday on Renewal Date) Restructured Hospital : Ward C: $1,500 Ward B2: $2,000 Ward B1: $2,500 Ward A: $3,500 Short-stay ward (non-subsidised): $2,000 Short-stay ward (subsidised): $1,500 Day Surgery (non-subsidised): $2,500 Day Surgery (subsidised): $2,000 Private Hospital and Hospital outside Singapore: All ward types & Day Surgery: $3,500 (5) (6) Does not apply to Outpatient Benefits Deductibles will increase by 50% when the Life Assured is above age 85 years next birthday on Renewal Date CO-INSURANCE P Plus A Plus B Plus 10% 10% 10% LIMITS ON BENEFITS PAYABLE P Plus A Plus B Plus Annual Benefit Limit $600,000 $400,000 $200,000 Lifetime Benefit Limit Unlimited Unlimited Unlimited 3 SupremeHealth Plan Policy Version 08/13

6 GREAT EASTERN LIFE SUPREMEHEALTH PLAN POLICY VERSION 08/13 (AS CHARGED) 1. POLICY DEFINITIONS The following clauses are defined as stated below and apply wherever they appear in this Policy: 1.1 Special Definitions Physician Any physician qualified by degree in Western medicine and legally licensed and authorised to practise medicine and surgery in the geographical area of his practice, other than the Policyholder, the Life Assured or a family member of either Hospital An establishment constituted and registered as a hospital for the care and treatment of sick and injured persons as bed-paying patients and which: Has facilities for diagnosis and major surgery, provides 24 hours a day nursing services by registered graduate nurses and is under the constant supervision of a Physician; or Is a Government / restructured specialist medical centre. However, the term Hospital does not refer to a clinic, an alcoholic or drug rehabilitation centre, a nursing, rest or convalescent home, a spa or a hydroclinic, a Community Hospital or similar establishment Hospitalisation Confinement of the Life Assured in a Hospital: for 12 consecutive hours or longer; or for which a room and board charge is made in connection with such confinement; or (c) is required because of a surgical procedure Accident An event that results in a sudden, unforeseen and involuntary Injury, and that event occurs independently of an illness, disease or any other causes Injury Damage of bodily tissues that is not sustained as a result of an illness or disease Emergency A serious Injury or illness or the onset of a serious medical condition which, in the opinion of the Company, requires urgent remedial treatment to avoid death or serious impairment to the Life Assured s immediate or long-term health Period of Insurance The Period of Insurance stated in Schedule A or any subsequent Period of Insurance as effected in accordance with Clauses and Effective Date of Cancellation The date of cancellation advised in the notice of cancellation or date of receipt of the notice of cancellation by the Company, whichever is later Renewal Date The date immediately following the last day of any Period of Insurance Commencement Date of Insurance of the Life Assured The date ( this date ) on which this SupremeHealth Plan insurance on the Life Assured first began, whether under this Policy or any policy for which insurance under this Policy is a 4 SupremeHealth Plan Policy Version 08/13

7 subsequent renewal or reinstatement. This date shall be the first day of the month of successful deduction from the Policyholder s Medisave account and/or during which the full premium is paid by the Policyholder, or such date as determined and advised by the Company Last Policy Effective Date The latest date of: (i) The Commencement Date of Insurance of the Life Assured; or (ii) The last Date of Reinstatement of the Policy; or (iii) The last effective date of upgrading of the Policy Medically Necessary A medical service which is: consistent with the diagnosis and customary medical treatment for a covered illness or Injury; in accordance with the standards of good medical practice, consistent with current standard of professional medical care, and of proven medical benefits; (c) not for the convenience of the Life Assured or the Physician, and unable to be reasonably rendered out of Hospital (if admitted as an inpatient); and (d) not of an investigational or research nature, preventive or screening nature Eligible Expenses Eligible Expenses are Expenses (as defined under Clause 1.2) incurred for Medically Necessary treatment provided to the Life Assured for Injury, illness or disease during the Period of Insurance. Eligible Expenses include Goods & Services Tax (GST) but exclude any other government taxes payable on such expenses Aggregate Eligible Expenses The Aggregate Eligible Expenses for the Life Assured is the sum of all Eligible Expenses incurred by the Life Assured during the Period of Insurance, subject to the limits as stated in Clause 3 of this Policy. On the Commencement Date of Insurance of the Life Assured and on each subsequent Renewal Date of this Policy, the Aggregate Eligible Expenses for the Period of Insurance which follows that date is nil Deductible The amount of the Aggregate Eligible Expenses (other than Eligible Expenses for Kidney Dialysis Treatment, Cancer Treatment, Erythropoietin and Immunosuppressant drugs prescribed for treatment of organ transplants provided to the Life Assured on an outpatient basis) incurred during the Period of Insurance which will be borne by the Policyholder before any benefit becomes payable under this Policy Co-insurance The share of the Aggregate Eligible Expenses incurred during the Period of Insurance in excess of the Deductible which is borne by the Policyholder Country of Issue The Country in which this Policy is issued as stated in Schedule A The Act refers to the Central Provident Fund Act (Chapter 36) The Regulations refer to the Central Provident Fund (MediShield Scheme) Regulations 2005 and any other revised future edition of the Regulations MediShield refers to the plan operated by the Central Provident Fund (CPF) Board, which is governed by the Act and the Regulations. 5 SupremeHealth Plan Policy Version 08/13

8 Policyholder s Medisave Account refers to the Policyholder s Central Provident Fund (CPF) Medisave account Community Hospital Any approved community hospital defined in regulation 2 of the Regulations Reasonable & Customary Charges Charges applicable for similar or comparable treatment or services provided in the Class of ward in accordance with the Plan Type insured for the Life Assured to individuals of the same sex and comparable age for similar illness, disease, disability or Injury Government The government of the Republic of Singapore Restructured Hospital A Hospital that is run as a private company and is wholly-owned by the Government through the Ministry of Health, Singapore, and that receives a government subsidy for the provision of subsidised medical services to its patients Foreigner A person who is not a citizen nor a permanent resident of Singapore Electronic Claims Filing System The electronic claims filing system set up by the Ministry of Health, Singapore. 1.2 Expenses The Expenses incurred by the Life Assured in respect of the following items are defined as Expenses: Daily Room & Board Accommodation in a Hospital including meals and general nursing during confinement as a bedpaying patient. This excludes deluxe rooms, luxury suites or other special rooms that are available in the Hospital Intensive Care Confinement in the intensive care ward of a Hospital Short-stay Ward Confinement in the short-stay ward in an accident and emergency department of a Hospital Miscellaneous Hospital Services Drugs and medicines, dressings, splints and plaster casts, intravenous infusions and blood transfusions, anaesthetics (other than that required for surgery) and oxygen and their administration Surgery Surgical operations in a Hospital (regardless of whether the Life Assured is Hospitalised or not) and performed by a duly qualified Physician and involving local or general anaesthesia. Surgery Expenses include the fees and charges for anaesthetics and oxygen and their administration and use of operating theatre and facilities. Surgery excludes Accidental Dental Treatment Daily In-Hospital Physician s Visit Consultation by a Physician during confinement in a Hospital Pre-Hospital Specialist s Consultation 6 SupremeHealth Plan Policy Version 08/13

9 Consultation by a specialist Physician ( such consultation ) upon recommendation by a nonspecialist Physician (general practitioner) and in connection with a medical condition which results in: (c) (d) Hospitalisation; or Surgery; or Kidney Dialysis Treatment; or Cancer Treatment, within 120 days of such consultation. Such consultation must take place in a Hospital or in a medical clinic where the specialist Physician customarily provides such consultations. However, such consultation would exclude consultations while the Life Assured is Hospitalised or which is provided after discharge from a Hospital Examination & Laboratory Tests Examinations using instruments and laboratory tests ( such examinations ) ordered by a Physician and performed: during the period of Hospitalisation; or in the course of diagnosis of a condition resulting in Hospitalisation, Surgery, Kidney Dialysis Treatment or Cancer Treatment within 120 days of such examinations Post-Hospital Follow-Up Treatment Medical treatment received after discharge from a Hospital ( post-hospital treatment ) provided the treatment is prescribed by a Physician and resulted directly from the condition for which Hospitalisation was required and includes: (c) General Outpatient services provided by a non-specialist Physician (general practitioner); or Specialist Outpatient services provided by a specialist Physician; or Instrument Examinations and Laboratory Tests ordered by a Physician, in a Hospital or in a medical clinic where the Physician customarily provides such services or in a duly licensed medical laboratory where such instrument examinations and laboratory tests are conducted. The post-hospital treatment must take place within 120 days from the date of discharge from a Hospital. Post-Hospital Follow-up Treatment excludes Kidney Dialysis Treatment and Cancer Treatment. Administration of Erythropoietin and Immunosuppressant drugs prescribed for treatment of organ transplants are also excluded Accidental Dental Treatment Dental procedures performed by a duly qualified dental surgeon necessary to restore or replace sound natural teeth lost or damaged during an Accident. Such dental procedures must take place during Hospitalisation of the Life Assured. Dental procedures performed other than in a Hospital will not be covered Kidney Dialysis Treatment In-hospital and outpatient kidney dialysis performed at a Hospital or a legally registered dialysis centre including examinations and tests ordered by a Physician during the course of the treatment. The Kidney Dialysis Treatment includes the formulated solution prescribed by a Physician and purchased from a Hospital or a legally registered dialysis centre for peritoneal dialysis, which is not required to be performed at a Hospital or a legally registered dialysis centre. Any additional formulated solution not prescribed by the Physician will not be covered. In addition, the cost of purchase or rental of the machine and apparatus for peritoneal dialysis and the costs for prescribed medications apart from Erythropoietin will not be covered. 7 SupremeHealth Plan Policy Version 08/13

10 Cancer Treatment Chemotherapy, radiotherapy, immunotherapy and/or stereotactic radiotherapy provided by a Hospital or a legally registered cancer treatment centre, including examinations and tests ordered by a Physician during the course of the treatment Surgical Implant/Approved Medical Consumables Surgical Implant refers to an implant inserted into the body of the Life Assured during surgery and remains in the body of the Life Assured on completion of the surgery. Approved Medical Consumables includes any of the following: intravascular electrodes used for electrophysiological procedures; Percutaneous Transluminal Coronary Angioplasty (PTCA); or (c) inter-aortic balloons (or balloon catheters) Human Immunodeficiency Virus ( HIV ) Due to Blood Transfusion and Occupationally Acquired HIV Infection with the HIV through a blood transfusion, provided that all of the following conditions are met: (c) (d) The blood transfusion was Medically Necessary or given as part of a medical treatment; The blood transfusion was received in Singapore after the Last Policy Effective Date; The source of the infection is established to be from the Hospital that provided the blood transfusion and the Hospital is able to trace the origin of the HIV tainted blood; and The Life Assured does not suffer from Thalassaemia Major or Haemophilia Infection with HIV which resulted from an Accident occurring after the Last Policy Effective Date, whilst the Life Assured was carrying out the normal professional duties of his or her own occupation in Singapore, provided that all of the following are proven to the Company s satisfaction: (c) (d) Proof of the Accident giving rise to the infection must be reported to the Company within 30 days of the accident taking place; Proof that the Accident involved a definite source of the HIV infected fluids; Proof of sero-conversion from HIV negative to HIV positive occurring during the 180 days after the documented Accident. This proof must include a negative HIV antibody test conducted within 5 days of the Accident; and Proof that the Life Assured is a medical practitioner, a houseman in a Hospital, medical student, registered nurse, medical laboratory technician, dental surgeon, dental nurse or paramedical worker, working in a medical centre or medical clinic in Singapore Pregnancy and Childbirth Complications One of the following complications arising from a pregnancy or childbirth, even if it results in Caesarean section, vacuum extraction or forceps delivery: Ectopic pregnancy; Pre-Eclampsia or Eclampsia; (c) (d) (e) (f) (g) Disseminated intravascular coagulation; Miscarriage after the first trimester of the pregnancy, which is an involuntary termination of the pregnancy as a direct consequence of a medical event or Accident that threatens the life of the pregnant person or the unborn fetus; Antepartum haemorrhage; Intrauterine death; Choriocarcinoma and hydatidiform mole, which is the occurrence of a histologically confirmed choriocarcinoma and/or molar pregnancy; 8 SupremeHealth Plan Policy Version 08/13

11 (h) (i) (j) (k) Acute fatty liver pregnancy; Breech delivery; Placenta previa; Post partum haemorrhage. The complication must be first diagnosed after 300 days from the Last Policy Effective Date Congenital Abnormalities Treatment relating to birth defects, including hereditary conditions, and congenital sickness or abnormalities first diagnosed from the Last Policy Effective Date Living Organ Donor Transplant (Kidney / Liver) All Expenses incurred by the Life Assured arising from transplanting his kidney or liver where the recipient of the kidney or liver is the Life Assured s family member, and where the recipient s kidney or liver failure is only first diagnosed after 730 days from the Last Policy Effective Date. For the purposes of this Expense only, the Life Assured s family members are deemed to be his parents, siblings, children and spouse Stem Cell Transplant All Expenses incurred by the Life Assured arising from the treatment of an illness or a medical condition. Outpatient therapy such as an injection or extraction where there is no Surgery or Hospitalisation involved will not be covered. Related costs including costs of harvesting, storage, transportation and cell culture will also not be covered Breast Reconstruction after Mastectomy Reconstructive surgery of the breast on which a mastectomy has been performed as a treatment of breast cancer. The breast reconstruction surgery must be performed by a Physician within 365 days from the date of the original mastectomy. The breast cancer must be first diagnosed after the Last Policy Effective Date. Any surgery or reconstruction of the other breast to produce a symmetrical appearance will not be covered Final Expenses Benefit In the event of the Life Assured s death during Hospitalisation or after discharge from Hospital, the Deductible and Co-insurance which applies to the Eligible Expenses (or proportionately reduced Eligible Expenses under Clause 4.2.2) will be waived and Eligible Expenses (or proportionately reduced Eligible Expenses) incurred during the Period of Insurance in which death occurs which will otherwise not have been reimbursed due to the application of the Deductible and Co-Insurance provisions will be reimbursed up to the limits stated in Schedule B for the Plan Type insured, except if the Life Assured dies as a result of self-inflicted injuries, suicide or attempted suicide, whether sane or insane. 1.3 Psychiatric Treatment Psychiatric treatment ( such psychiatric treatment ) provided to the Life Assured by a Physician during full-time confinement in a Hospital including the following provided to the Life Assured in connection with such psychiatric treatment: Pre-Hospital Specialist s Consultation; Examination & Laboratory Tests: or (c) Post-Hospital Follow-Up Treatment. For the avoidance of doubt, all Eligible Expenses incurred above are accumulated up to a limit for Psychiatric Treatment as provided in Schedule B. 2 LIFE ASSURED JOINTLY INSURED UNDER MEDISHIELD 9 SupremeHealth Plan Policy Version 08/13

12 The Life Assured is also jointly insured under MediShield operated by the Central Provident Fund Board which is governed by the Act and the Regulations, provided the Life Assured meets the eligibility conditions as specified in the Act and the Regulations. The Life Assured, if insured under MediShield, shall enjoy all benefits of MediShield as provided under the Act and the Regulations. 3 LIMITS ON ELIGIBLE EXPENSES Eligible Expenses are: limited to the Reasonable and Customary Charges for such Expenses; and subject to the limits as stated in Schedule B of this Policy in accordance with the Plan Type insured at the time such Expenses are incurred. 4 BENEFITS 4.1 Subject to Clauses and Conditions Subject to the clauses and conditions of this Policy, the Company will pay benefits under this Policy for any Eligible Expenses incurred by the Life Assured during the Period of Insurance. If the benefits payable under MediShield are higher than the benefits payable for the Eligible Expenses according to Clause 4.2 to 4.5 below, the Company will pay the benefits under MediShield Subject to the clauses and conditions of this Policy, any claim for Eligible Expenses incurred after the Commencement Date of Insurance of the Life Assured shall only be paid after the Company receives the full payment of the premium for the Period of Insurance during which the Eligible Expenses are incurred. 4.2 Reimbursement of Eligible Expenses The Company will pay benefits under this Policy by way of reimbursement of Eligible Expenses incurred subject to the limits as stated in Clause 3 above Pro-ration Factor A Plus Subject to Clause , if the Life Assured is insured under A Plus as indicated in Schedule A of this Policy and incurs Eligible Expenses while warded in: a private Hospital; or any Class or type of ward of a Restructured Hospital for which such Restructured Hospital does not receive any subsidy from the Government for the provision of medical services to the Life Assured while confined in that Class or type of ward (other than the Class A ward of such Restructured Hospital), which the Company may at its discretion include under this Clause from time to time, all such Eligible Expenses will first be proportionately reduced by multiplying the Pro-ration Factor shown for A Plus in Schedule B with the original amounts of such Expenses. The proportionately reduced Expenses will then be subject to the Deductibles, Co-insurance and Limits stated in Schedule B. For the avoidance of doubt, all Expenses in excess of the proportionately reduced Expenses will not be reimbursed by the Company. 10 SupremeHealth Plan Policy Version 08/13

13 B Plus Subject to Clause , if the Life Assured is insured under B Plus as indicated in Schedule A of this Policy and incurs Eligible Expenses in: (c) (d) a private Hospital; or a Class A ward of a Restructured Hospital; or any Class or type of ward of a Restructured Hospital for which such Restructured Hospital does not receive any subsidy from the Government for the provision of medical services to the Life Assured while confined in that Class or type of Ward, which the Company may at its discretion include under this Clause from time to time; or any Class or type of ward of a Restructured Hospital for which such Restructured Hospital receives a lower subsidy from the Government for the provision of medical services to the Life Assured while confined in that Class or type of ward than the subsidy such Restructured Hospital receives for the provision of the same services for a patient confined in a Class B1 ward of such Restructured Hospital, and which the Company may at its discretion include under this Clause from time to time, any such Eligible Expenses will first be proportionately reduced by multiplying the Pro-ration Factor shown for B Plus in Schedule B with the original amounts of such Expenses. The proportionately reduced Expenses will then be subject to the Deductibles, Co-insurance and Limits stated in Schedule B. For the avoidance of doubt, all Expenses in excess of the proportionately reduced Expenses will not be reimbursed by the Company Subject to Clause and Clause , if the Life Assured: (c) is insured under B Plus as indicated in Schedule A of this Policy; and incurs Eligible Expenses in a class B1 ward or lower ward in a Restructured Hospital; and the Life Assured is a Singapore Permanent Resident or Foreigner when such Eligible Expenses were incurred, any such Eligible Expenses will first be proportionately reduced by multiplying the Pro-ration Factor shown in the table below applicable to his citizenship status when such Eligible Expenses were incurred, with the original amounts of such Expenses. The proportionately reduced Expenses will then be subject to the Deductibles, Co-insurance and Limits stated in Schedule B. For the avoidance of doubt, all Expenses in excess of the proportionately reduced Expenses will not be reimbursed by the Company. Singapore Permanent Resident Pro-ration Factor Foreigner Pro-ration Factor 90% 80% Expenses incurred in a Restructured Hospital for any of the following treatments provided to the Life Assured on an outpatient basis will not be pro-rated in accordance with Clauses , and : 11 SupremeHealth Plan Policy Version 08/13

14 (c) (d) Kidney Dialysis Treatment; or Cancer Treatment; or Erythropoietin; or Immunosuppressant drugs prescribed for treatment of organ transplants If the Life Assured undergoes Hospitalisation in a Restructured Hospital but, during the Hospitalisation, transfers from a Class or type of ward to another Class or type of ward for which the Restructured Hospital receives a higher or lower or no subsidy from the Government for the provision of medical services to the Life Assured, the Pro-ration Factor which applies to the Expenses incurred during the whole period of Hospitalisation will be that applicable to the Class or type of ward for which the Restructured Hospital receives the lowest subsidy from the Government, in accordance with Clauses or For any benefits payable under this Policy, the Company will make payment to the Hospital, medical clinic or other medical establishment using the Electronic Claims Filing System with which it has a payment arrangement. Otherwise, the Company will make payment directly to the Policyholder or the Policyholder s legal personal representative(s) If the Life Assured has undergone Hospitalisation in a Hospital ( that Hospital ) after the Last Policy Effective Date and: is discharged from that Hospital; and a Physician in that Hospital has recommended in writing that the Life Assured is to be confined as an inpatient in a Community Hospital for further medical treatment arising from the same Injury, illness or disease that resulted in the Life Assured s Hospitalisation in that Hospital, the Company will reimburse Eligible Expenses incurred arising from the Life Assured s confinement in the Community Hospital including expenses for accommodation, meals and general nursing during the Life Assured s confinement as a bed-paying patient in the Community Hospital subject to the limits as stated in Schedule B of this Policy in accordance with the Plan Type insured at the time such Eligible Expenses were incurred. 4.3 Benefit Computation The Company will not pay benefits in respect of the Life Assured unless the Aggregate Eligible Expenses (other than Eligible Expenses for Kidney Dialysis Treatment, Cancer Treatment, Erythropoietin or Immunosuppressant drugs prescribed for treatment of organ transplants provided to the Life Assured on an outpatient basis) incurred during any Period of Insurance exceeds the Deductible effective during that Period of Insurance. If there are two or more Deductibles that can be applied, the Company will apply the highest Deductible If the Aggregate Eligible Expenses (other than the Eligible Expenses for Kidney Dialysis Treatment, Cancer Treatment, Erythropoietin or Immunosuppressant drugs prescribed for treatment of organ transplants provided to the Life Assured on an outpatient basis) exceeds the Deductible, the benefit payable shall be the reimbursement of the Aggregate Eligible Expenses in excess of the Deductible, less the Co-insurance applicable to that Period of Insurance The Company will pay benefits in respect of the Eligible Expenses incurred for Kidney Dialysis Treatment, Cancer Treatment, Erythropoietin, Immunosuppressant drugs prescribed for treatment of organ transplants provided to the Life Assured on an outpatient basis, without deducting the Deductible but after deducting the Co-insurance applicable to that Period of Insurance. 12 SupremeHealth Plan Policy Version 08/13

15 4.4 Benefit Limits The Company will pay benefits in respect of Eligible Expenses incurred for treatment provided to the Life Assured during the Period of Insurance up to the Annual Benefit Limit as stated in Schedule B, in accordance with the Plan Type insured for the Life Assured at the time such Expenses are incurred The Annual Benefit Limit in Schedule B on benefits payable for Psychiatric Treatment will apply to the total of all Eligible Expenses incurred in respect of and in connection with such Psychiatric Treatment The Benefit Limit per Transplant in Schedule B on Expenses of Living Organ Donor Transplant (Kidney / Liver) will apply to the total of all Expenses incurred in respect of and in connection with such Living Organ Donor Transplant (Kidney / Liver) The Annual Benefit Limit in Schedule B on benefits payable for Congenital Abnormalities will apply to the total of all Eligible Expenses incurred in respect of and in connection with such Congenital Abnormalities. 4.5 Indemnity and Last Payer Status Benefits payable under this Policy, together with reimbursement of Expenses paid or payable from other sources, other insurance policies and employment benefit provisions will not exceed the Expenses actually incurred in respect of any claim made under this Policy. If the Life Assured is entitled to reimbursement for the Expenses incurred in respect of any claim from other sources, including other insurance policies and employment benefits, the Company shall be the last payer reimbursing the claim. If any Expenses payable under this Policy has been made to the Policyholder first before a claim is made under such other medical insurance policies or employee benefits or other sources, the other medical insurers or employer or such other source will need to reimburse the Company their share. The Policyholder shall provide the Company with the full details of such other insurance policies or employee benefits and all relevant documentary proof necessary to make a claim. 5 EXCLUSIONS 5.1 General Exclusions Under this Policy, the Company will not pay any benefit in reimbursement of Expenses incurred for, or for the consequences of, the following: (c) (d) (e) (f) Pregnancy and childbirth (including Caesarean section, vacuum extraction or forceps delivery and the consequences thereof) except for Pregnancy and Childbirth Complications. Elective abortion, spontaneous miscarriage occurring within first trimester of pregnancy, birth control*, sterilization*, infertility*, sub-fertility* or impotence treatment. * for male or female Routine physical or any other examinations not related to the treatment or diagnosis of an Injury, illness or disease. Instrument examinations and laboratory tests not ordered by a Physician or not resulting in a diagnosis of a condition leading to Hospitalisation, Surgery, Kidney Dialysis Treatment, Cancer Treatment or Accidental Dental Treatment. All Dental Treatment not defined as Accidental Dental Treatment. Elective cosmetic or plastic surgery except for: (i) Breast Reconstruction after Mastectomy; and (ii) Injury sustained as a result of an Accident, which occurs after the Last Policy Effective Date. 13 SupremeHealth Plan Policy Version 08/13

16 (g) (h) (i) (j) (k) (l) (m) (n) (o) (p) (q) (r) (s) (t) (u) Treatment of psychiatric, emotional, personality, mental and nervous disorders including depression (except for Psychiatric Treatment if covered under this Policy as indicated in Schedule B). Treatment of alcoholism or drug abuse. Treatment provided to the Life Assured by the Policyholder, or a family member of the Life Assured or the Policyholder, or self-treatment by the Life Assured, including the prescription of drugs. Transport for trips made for the purpose of obtaining medical treatment. Purchase and rental of prostheses, corrective devices and medical appliances unless the prostheses, corrective device or medical appliance satisfies the definition of a Surgical Implant or of Approved Medical Consumables. Medical appliances include but are not limited to kidney dialysis machines, iron lung, and durable medical equipment (e.g. wheelchairs and hospital beds) used at home. Acquisition of the organ itself for an organ transplant, (except for the procurement costs incurred directly by the Hospital for the procurement of the organ for transplantation into the Life Assured where the donor of the organ is already dead at the time of the removal of any of the organs in the Country of Issue or outside the Country of Issue). All Expenses incurred by the donor for an organ transplant except for Living Organ Donor Transplant (Kidney / Liver). Self-inflicted injuries or suicide or attempted suicide, whether sane or insane. AIDS and all illnesses or diseases caused by or related to the Human Immunodeficiency Virus ( HIV ) except for Human Immunodeficiency Virus ( HIV ) Due to Blood Transfusion and Occupationally Acquired HIV. Sexually-transmitted diseases. Violation or attempted violation of law and resistance to lawful arrest or any resultant imprisonment. War (whether declared or not), invasion, terrorist activities, rebellion, revolution, civil war or any warlike operations. Being in or on an aircraft of any type, or boarding or descending from any aircraft, except as a fare-paying passenger or crew member on an aircraft on a regular scheduled route operated by a recognised airline. The Life Assured engaging in any sport in a professional capacity or where the Life Assured would or could earn income or remuneration or win monetary rewards from engaging in such sport. Medical treatment, Hospitalisation, Surgery and consultation provided to and investigation of the Life Assured commencing: (i) Before the Commencement Date of Insurance of the Life Assured for any condition; (v) (ii) On or after the Commencement Date of Insurance of the Life Assured which are follow-up medical treatment(s), consultation(s) or further investigation(s) of the Life Assured for that condition for which he received medical treatment, consultation or investigation before the Commencement Date of Insurance of the Life Assured. Any treatment provided to the Life Assured after the Renewal Date of this Policy unless the insurance has been renewed on or before that date in accordance with Clause 8 of this Policy. 14 SupremeHealth Plan Policy Version 08/13

17 (w) (x) (y) (z) (aa) (bb) (cc) (dd) Private nursing charges and nursing home services. Medical or surgical treatment outside Singapore except in the case of an Emergency. Treatment for obesity, weight reduction or weight improvement regardless of whether it is Medically Necessary or otherwise. Ambulance fee. Vaccination. Correction for refractive errors of the eye, routine eye and eye examinations, costs of spectacles, costs of contact lenses and costs of hearing aids. Mountaineering, diving, bungee jumping, racing other than racing on foot, wakeboarding, hanggliding, rock climbing, parachuting, ballooning, handling of explosives or firearms and all activities which are potentially life-threatening or where there is a risk of bodily injury to the Life Assured. Ionizing radiation or contamination by radioactivity from any nuclear fuel or nuclear waste from process of nuclear fission or from any nuclear weapons material. 5.2 Pre-existing Conditions Any pre-existing illnesses, diseases or impairments ( Pre-existing Conditions ) from which the Life Assured is suffering prior to the Commencement Date of Insurance of the Life Assured are excluded, unless declared in the proposal for (or in the application for reinstatement of) insurance of the Life Assured and expressly accepted by the Company Subject to Clause below, any Pre-existing Condition which qualifies under any exclusions under Clause 5.1 above is automatically excluded regardless of whether a declaration has been made of that condition in the proposal for, or in the application for the reinstatement of, the insurance under this Policy and accepted by the Company However, Pre-existing Conditions which had been covered under MediShield immediately before the Commencement Date of Insurance of the Life Assured will continue to be covered under MediShield provided that : the Life Assured was insured under : (i) MediShield; or (ii) any policy included in the Integrated Private Medical Insurance Scheme (IPMIS) under which the Life Assured was jointly insured under MediShield, immediately before the Commencement Date of Insurance of the Life Assured; and the Life Assured is now jointly insured under MediShield in accordance to Clause 2 above. 5.3 Expenses Falling under Exclusion Expenses incurred for medical treatment and consultation provided to and investigation of the Life Assured under any of the exclusions as listed in Clauses 5.1 and 5.2 above will not be part of Eligible Expenses, and will not be added to the Aggregate Eligible Expenses, if no benefit payment is made in respect of these Expenses. 6 TERRITORIAL FACTORS 6.1 Overseas Emergency Medical Treatment 15 SupremeHealth Plan Policy Version 08/13

18 If the Life Assured requires medical or surgical treatment as a result of an Emergency while outside Singapore, the Company shall reimburse the Expenses incurred up to the Limits stated in Schedule B subject to the following conditions: (c) If the Life Assured is insured under P Plus at the time such Expenses were incurred, the Company will reimburse the Expenses incurred or the Reasonable and Customary Charges which would have been incurred for similar medical or surgical treatment in any private Hospital in Singapore, whichever is lower. If the Life Assured is insured under A Plus at the time such Expenses were incurred, the Company will reimburse the Expenses incurred or the Reasonable and Customary Charges which would have been incurred for similar medical or surgical treatment in any Class A ward of a Restructured Hospital in Singapore, whichever is lower. If the Life Assured is insured under B Plus at the time such Expenses were incurred, the Company will reimburse the Expenses incurred or the Reasonable and Customary Charges which would have been incurred for similar medical or surgical treatment in any Class B1 ward of a Restructured Hospital in Singapore, whichever is lower. 6.2 Currency Exchange Expenses incurred as a result of an Emergency while outside Singapore in any currency other than the Singapore Dollar will be converted to Singapore currency at the prevailing exchange rate as determined by the Company to be in effect on the date the Expenses were incurred. 7 TERMINATION 7.1 Termination on Renewal Date On any Renewal Date of this Policy, insurance on the Life Assured under this Policy will end unless the insurance has been renewed in accordance with Clause 8 below. 7.2 Death of Policyholder or Life Assured If the Policyholder dies and the Policyholder is not the Life Assured, this Policy will continue for the Life Assured until the Renewal Date of this Policy following the date of the death. On the Renewal Date, the Company will insure the Life Assured under a new Policy for the same Plan Type insured for the Life Assured effective on the day before the Renewal Date without requiring fresh evidence of insurability, subject to the following conditions: A party must submit a fresh proposal before the Renewal Date and; (i) (ii) that party must be allowed to deduct premiums for the Life Assured from that party s Medisave account with the Central Provident Fund (CPF) Board ( that party s Medisave account ) if the premium for the new policy is to be paid entirely or partially from that party s Medisave account; or if the premium for the new policy is to be paid entirely in cash, that party must have valid insurable interest on the Life Assured; The new policy issued in accordance with Clause will be issued on the clauses and conditions of the Policy Version existing as at the Renewal Date; and (c) Any endorsement on or variation to this Policy authorised by the Company will also apply to the new policy issued unless otherwise agreed by the Company Insurance on the Life Assured will end upon the death of the Life Assured. The Policyholder [or the Policyholder's legal personal representative(s)] is entitled to a pro-rated refund of premium (if paid) in respect of the insurance on the deceased Life Assured for the period remaining up to the Renewal Date, after the date of death. 7.3 Cancellation By Policyholder 16 SupremeHealth Plan Policy Version 08/13

19 7.3.1 The Policyholder may cancel this Policy by submitting a notice of cancellation to the Company upon which this Policy will be treated as ended on the Effective Date of Cancellation The insurance on the Life Assured will end on the Effective Date of Cancellation Upon termination of this Policy by cancellation, the Policyholder is entitled to a full refund of premium, if the Effective Date of Cancellation falls within the first two calendar months after the Commencement Date of Insurance of the Life Assured If the Effective Date of Cancellation falls outside the first two calendar months as mentioned in Clause above, the premium will be refunded on a pro-rated basis allowing for the actual number of days this Policy was in force from the: Commencement Date of Insurance of the Life Assured; or Renewal Date, preceding the Effective Date of Cancellation, where applicable, except for a pro-rated amount of the corresponding premium for MediShield for the Life Assured under the Act and the Regulations. After the Effective Date of Cancellation, the Life Assured will be covered under MediShield provided the Life Assured meets the eligibility conditions as specified in the Act and the Regulations If no Effective Date of Cancellation is specified in the notice of cancellation, the Company will assume the Effective Date of Cancellation to be the date of receipt of the notice of cancellation by the Company. 7.4 Not Citizen or Permanent Resident : Residence Overseas Insurance for the Life Assured will end on the Renewal Date ( that Renewal Date ) of this Policy and will not be renewed if, on that date, the Life Assured: Is not a citizen or permanent resident of the Country of Issue; and (c) Has resided outside the Country of Issue for more than 180 days, whether continuously or otherwise during the Period of Insurance immediately prior to that Renewal Date; and Is still residing outside the Country of Issue. 7.5 Life Assured Insured Under Another Shield Plan The insurance under this Policy will terminate immediately, when the Life Assured is subsequently insured under a similar plan issued under the Regulations by another insurance company. 7.6 No Benefits Payable after Termination of Insurance The Company will not pay any benefit in reimbursement of any Expenses incurred by the Life Assured whose insurance has ended in accordance with Clauses 7.3, 7.4 or 7.5 above for treatment provided to the Life Assured on or after the effective date of such termination The Company will not pay any benefit for any Expenses incurred by the Life Assured for treatment provided to the Life Assured on or after a Renewal Date of this Policy unless insurance for the Life Assured was renewed in accordance with Clause 8 below. 8 RENEWAL 8.1 When No Renewal Allowed The Company will not renew insurance under this Policy for the Life Assured whose insurance has ended in accordance with Clauses 7.3, 7.4 or 7.5 above. 8.2 Renewal upon Payment of Premium 17 SupremeHealth Plan Policy Version 08/13

20 8.2.1 Subject to Clause 8.1, if the required premium for renewal is paid on or before a Renewal Date, the Company will guarantee the renewal of this Policy for a further Period of Insurance. The further Period of Insurance will begin on the Renewal Date Where the premium is to be paid from the Policyholder s Medisave account, the Company shall request for deduction of the premium from the Policyholder s Medisave account, subject to the limits under the Central Provident Fund (Private Medical Insurance Scheme) Regulations ( PMIS regulations ) effective at the time of request The excess of the premium for the Life Assured over the PMIS regulations limit, and any shortfall in the deduction of premium resulting from the Policyholder s CPF Medisave account being inadequate, must be paid by the Policyholder before the end of the Grace Period described in Clause below All endorsements on or variations to this Policy authorised by the Company and any premium loading imposed will also apply to the insurance granted on this Policy s renewal unless otherwise agreed in writing by the Company. 8.3 Grace Period The Policyholder has a period of 60 days ( the Grace Period ) from the Renewal Date including the Renewal Date, to pay the required renewal premium. If the full renewal premium is not paid on or before the last day of the Grace Period, insurance under this Policy will be treated as ended on the Renewal Date and may only be reinstated with the consent of the Company If the Life Assured receives treatment for which Eligible Expenses are incurred during the Grace Period and a claim is submitted and there is still an amount of renewal premium to be paid ( the balance unpaid premium ) or the renewal premium ( outstanding renewal premium ) has not been paid yet, the Company will not pay any benefits for any claim submitted until the balance unpaid premium or the outstanding renewal premium is paid before the end of the Grace Period If during the Grace Period, insurance on the Life Assured begins under any policy of insurance with the Company which also provides benefits payable as defined in this Policy, then Clause will immediately be void on the date of commencement of such other insurance Clauses and will not apply to the Life Assured if insurance on the Life Assured will not be renewed in accordance with Clause 8.1 above. 8.4 Rate of Premium The required renewal premium for the Life Assured whose insurance is renewed will be calculated at the rate of premium applicable on the Renewal Date to: the Plan Type insured for the Life Assured and effective on the day before the Renewal Date (or for any other Plan Type subject to the agreement of the Company); and the age next birthday of the Life Assured on the Renewal Date, unless otherwise agreed in writing by the Company. 8.5 Company May Amend Clauses and Conditions and Premium Rates The Company may amend the clauses and conditions of the insurance at renewal provided that the amendments apply to all policies of this class of insurance and the Policyholder has been informed of the amendments at least 30 days before the Renewal Date at which time the amendments will apply The Company may amend the rates of premium at renewal provided that the amended rates apply to all policies of this class of insurance and the Policyholder has been informed of the amended rates at least 30 days before the Renewal Date at which time the amended rates will apply. 8.6 Upgrading/Downgrading of Plan Type The Policyholder may apply to: 18 SupremeHealth Plan Policy Version 08/13