EMPLOYEE BENEFITS HEALTH INSURANCE PLAN

Transcription

1 EMPLOYEE BENEFITS HEALTH INSURANCE PLAN Description AXA China Region offers: Health link Card China Health Link Network AXA Assistance will assist Insured Person to be admitted to an exclusive selected hospital in the People's Republic of China by presenting the Health Link Card. AXA Assistance will arrange and provide guarantee for any required hospital admission deposit. Providing Access to Worldwide Emergency Service You can access to the Inter Par tner Assistance Hong Kong Limited (Hotline:(852) ) when emergency assistance or enquir y is required outside Hong Kong. Member will need to identify himself by giving his name, company name, policy / certificate number (if possible), location and telephone contact number (please refer to the part of "Emergency Medical Evacuation" of the benefit booklet for details services). Care Card Cards will be issued to all eligible employees and dependants on written acceptance of their employer s application. The minimum requirement is at least 30 employees and payment by annual mode. This will enable your employees to receive medical treatment from a large number of doctors and hospitals in Hong Kong without the need to make any payment at the time of treatment other than the excess over their entitled benefit for a doctor s consultation. Card fee of HK$5 each will be charged for the Standard Health Insurance Plan, and for the Super Health Insurance Plan will be provided for free. Autopay System In the event your employees do not use their Care Cards, we will reimburse medical expenses incurred through daily autopay. Monitor and Control To inform you of the status of your health plan, we offer a comprehensive range of reports: semi-annual and annual claim analysis review of member s usage pattern for analysis and monitoring if possible and abuse (if any) claim history Benefits Benefits are payable for expenses that are actually incurred on a per disability basis unless specified otherwise. Benefits cannot exceed the maxima as stated in the Benefit Schedule. Hospital Room and Board covers charges for the room and food. Doctor s Visit covers the charges of the attending doctor. The cost is payable for both surgical and non-surgical situations. Hospital Expenses include prescribed medication, dressings, diagnostic X-rays, Lab tests and other customary hospital services. It includes anaesthetist s fees and the cost of the operating theatre if they are not separately insured. Surgeon s Fees cover an amount equal to the actual surgeon s charge, or an amount according to the specified operation under the Benefit Schedule, whichever is less. Anaesthetist s Fees pay an amount equal to the actual anaesthetist s charge, or an amount according to the specified operation under the Benefit Schedule, whichever is less. Operating Theatre covers an amount equal to the actual charge for the use of the operating theatre or an amount according to the specified operation under the Benefit Schedule, whichever is less. Specialist Consultation covers the charges of a medical specialist referred by the attending doctor. Nursing covers the charges of a qualified nurse, referred by the attending doctor, after discharge from hospital. Doctor's Visit Consultation by a registered medical practitioner while hospitalized. Intensive Care Unit Reimbursement of the room and board charges incurred while confined in an Intensive Care Unit of a hospital. Hospital Cash If the insured person is hospitalized in ward bed of public hospitals under the administration of the Hong Kong Hospital Authority, besides the reimbursement of the Room and Board Benefit, you will also be entitled to the additional Hospital Cash Benefit in respect of each Day of Hospital Confinement, up to the maximum limits specified in the Schedule of Benefits. Claim Procedures Claims will be settled through autopay into employee bank account and a claim settlement will be issued to each employee once the claim is processed. Employee will also be able to access the claim status and panel doctor network details through AXA China Region's website, Top Up Benefit for Hospitalization Overseas Increase 100% of basic hospitalization benefits for overseas hospitalization due to accident. (Exclude Hong Kong, Macau and People's Republic of China) EBNB

2 EMPLOYEE BENEFITS HEALTH INSURANCE PLAN Home Health Care Home Health Care is an alternative to hospitalisation. After at least 3 days in hospital, with the approval of the attending Doctor, patients now have an alternative to continue hospital standard healthcare in the comfort of their home. Benefits are payable for medically necessar y, reasonable and customar y charges incurred and supplies provided by the home health care agency approved by AXA China Region, up to the maximum benefit as stated in the Benefits schedule. That will include charges on: Nursing services Doctor s management fee Laboratory examination Medicine and drugs Medical supplies Rental of home health care equipment Rehabilitation, therapy etc. Careline facilities For the patient s additional peace of mind (when necessary), AXA China Region will help to install, free of charge, a Careline allowing the patient to talk to a 24 hour control room for emergency assistance and security, without having to pick up the phone or dial a number. Clinical Consultation at a Doctor s clinic covers consultation charges, injections, prescribed medication supplied by the physician. The cost of Diagnostic X-ray and Lab tests are covered if referred by the attending doctor. Specialist consultation covers the charges of a medical specialist referred by the attending doctor. Additional Benefit for Accident covers the expenses over and above the hospitalisation and clinical benefits if accidental bodily injury is incurred. Prescribed medication covers the charge of medicine and drugs, prescribed by the attending doctor, bought at a pharmacy. Bonesetter / Herbalist / Acupuncturist Covers the expenses of consultation and medicine charged by a Chinese Herbalist or Bonesetter or Acupuncturist. Supplementary Major Medical (SMM) SMM covers all necessary, reasonable and customary expenses in excess of the payable benefits for hospitalisation in the same or lower level of hospital accommodation under the basic plan. Benefit is payable on an 80% reimbursement basis after a predetermined initial deductible. Childbirth This benefit covers all the reasonable and customary expenses incurred as a result of pregnancy and the resulting birth. Co-ordination of Benefits The payable benefits shall be reduced by the amount of benefits to which the insured is entitled under the Employees s Compensation Ordinance or other health insurance plan. EBNB

3 EMPLOYEE BENEFITS HEALTH INSURANCE PLAN Exclusions Treatment in any hospital which is not registered with the government or consulting any person other than a registered doctor. Sickness or injury arising directly or indirectly from war or participation in any illegal acts (except traffic or pedestrian offences) General check up Dentistry (other than resulting from an accident) Eye refraction or the fitting or glasses Pre-existing Conditions Benefits shall not be payable: 1) for injuries or sickness sustained before participation and because of which medical treatment was received within 3 consecutive months immediately prior to joining the health insurance plan. However, provided no medical treatment is incurred for such injuries or sickness within any 3 consecutive months after participation, benefits shall subsequently become payable. 2) for any HIV-related infection contracted before participation in the plan. Elective surgery Congenital anomalies Pregnancy or other related expenses (if the Insured does not have maternity cover) Surgical or prosthetic appliances Physiotherapy treatment unless recommended by the attending doctor EBNB

4 DENTAL BENEFITS Description Preventive care, cleansing and oral check up covers the cost of professional prophylexis and oral examination. The cost of diagnostic X-rays for the preparation of removing a decayed or damaged portion of tooth and shaping of the tooth s structure to receive a filling or dental prosthesis. Extraction covers the cost of removing a tooth from the oral cavity. Filling covers the cost of the restoration of a tooth. Abscesses and relief of pain covers the cost for the necessary treatment and the subsequent relief of pain. Exclusions Treatment by any person other than a registered dentist. Replacement of lost or stolen prosthetic devices. Expenses for treatment arising from employment covered by employee compensation insurance or other insurance policies. Any loss caused by war or act of war whether declared or undeclared. Expenses incurred for oral hygiene instructions, plaque control programmes and dietary instructions. Dentures covers the cost of artificial replacements for one or more natural teeth resulting from an accident. Benefit is payable for simple dentures provided that the missing teeth are extracted while the Covered Person is insured. EBNB

5 EMERGENCY EVACUATION COVER Description AXA Assistance (IPA) Emer gency Ser vice ( AXA Assistance ) is provided by Inter Partner Assistance Hong Kong Limited ( IPA ). It provides assistance when an accident or emergency occurs outside Hong Kong necessitating urgent medical treatment, which is not available locally at the time of the emergency. The cover includes medically necessary transportation, appropriate medical care during transpor tation and ancillary services in moving the patient to the nearest medical facility where appropriate care is available. Benefits Telephone medical advice and evaluation, referral to doctors and specialists and the organisation of hospitalisation (emergency or non-emergency cases). Medical fees incurred are the responsibility of the Insured Person. Provision of a doctor and/or other medical personnel to the Insured Person when required. Deliver y of essential medication and medical equipment not available locally. The cost of the medication and/or equipment will be the responsibility of the Insured Person. Worldwide medical evacuation (Fully Covered). When adequate medical facilities are not available locally, a medically supervised evacuation to the nearest facility will be provided. Worldwide Guarantee of any required hospital admittance deposit of up to US$5,000. Medical monitoring during hospitalization and the provision of regular updates to the Insured Person s family and/or employer. Compassionate visit. Return economy class airline ticket for a person chosen by Insured Person / a relative to join the Insured Person who is hospitalized abroad for more than 7 consecutive days. Visitor accommodation expenses of up to US$1,000 are covered. Return of dependant children to the countr y of residence who are left unattended as a result of the Insured Person s hospitalization. One-way economy class airline ticket and a qualified escor t will be provided when required. One-way economy class airline ticket for the Insured Person to return his Countr y of Residence in the event of the accidental death of the Insured Person s Close Relative in his Country of Residence while the Insured Person is traveling overseas (excluding the case of immigration). Worldwide medically supervised repatriation (Fully Covered). When it is determined that treatment should continue in the Insured Person s countr y of residence after the patient s condition has stabilised, repatriation will be provided under medical supervision. Worldwide repatriation of mortal remains. Referral to lawyers for assistance. Legal fees (together with any fines imposed) of up to US$3,900 are covered. Referral to other ser vices e.g. interpreters and technicians. The Insured Person will be responsible for any fees charged by the services provider. Emergency Evacuation Plus In addition to the above, at a small additional cost, HK$200,000 top-up hospitalization cover can also be arranged by AXA China Region. Upon repatriation, AXA China Region will indemnify the Insured Person for medical expenses exceeding the normal hospitalization benefits. China Health Link Network AXA Assistance will assist Insured Person to be admitted to an exclusive selected hospital in the People s Republic of China by presenting the Health Link Card. AXA Assistance will arrange and provide guarantee for any required hospital admission deposit. EBNB

6 EMERGENCY EVACUATION COVER Limitation and Exclusions AXA Assistance (IPA) Emer gency Ser vice ( AXA Assistance ) is provided by Inter Partner Assistance Hong Kong Limited ( IPA ). AXA China Region accepts no liability for the ser vices provided by IPA or their availability. Neither AXA China Region nor IPA shall be liable for any Evacuation and/or Repatriation costs incurred in connection with or consequent upon: The provision of services which are not specified in the AXA Assistance Terms & Conditions, or during a period for which payment is not received from the Insured Services rendered without the authorization and/or intervention of AXA Assistance. Ser vices provided by any par ty other than AXA Assistance. Medical treatment administered by relatives. Expenses covered under any insurance policy. Cases of minor illness or injur y which can be adequately treated locally and which do not prevent the Insured Person from continuing his/her travel or work. Cases in which the Insured Person is able to return to the countr y of residence sitting as a normal passenger without a medical escort, unless deemed necessary by an AXA Assistance doctor. Cases in which the Insured Person was under medical treatment when commencing his/her journey and the costs concerned were relevant to that treatment, or if the journey was undertaken against medical advice. Cases in which a journey was undertaken with the intention of obtaining medical treatment. Cases related to psychiatric disorders or diseases. Expenses arising from willfully inflicted self-injur y or illness, insanity, alcoholism, drugs or substance abuse or self-exposure to needless peril (except in an attempt to save human life). Cases of pregnancy. The Insured Person exercising any form of hazardous work. The Insured Person engaging in any form of aerial flight except as a fare-paying passenger. Hazardous sports e.g. rock climbing, mountaineering, parachuting or any sport undertaken on a professional or competitive basis. Participation in illegal acts. Active service in the armed forces of any country. Declared or undeclared war or any act thereof. Loss as a direct result of nuclear reaction or radiation. AXA Assistance cannot guarantee nor shall it be responsible for the quality of such hospital and services provided to the Insured Person. The final selection of a hospital shall be the decision of the Insured Person. All hospital admission deposit funds guaranteed by AXA Assistance shall be unconditionally paid to the hospital by the Insured Person upon discharge from the hospital. AXA Assistance shall not be responsible for the investigation or merits of the claims nor be responsible for the interpretation of benefits, coverage or exclusions of the insurance policy of the Insured Person. More than one emergency evacuation and/or repatriation for any single medical condition of an Insured Person during the term of the Service Program. Any expense incurred as a result of Acquired Immune Deficiency Syndrome (AIDS) or any AIDS related condition or disease. Any expense, regardless of any contributory cause(s), involving the use of or release or the threat thereof of any nuclear weapon or device or chemical or biological agent, including but not limited to expenses in any way caused or contributed to by an Act of Terrorism or War. Act of Terrorism shall refer to an act, including but not limited to the use of force or violence and/or threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organisation(s) or government(s), committed for political, religious, ideological or ethnic purposes or reasons including the intention to influence any government and/or to put the public, or any section of the public, in fear. EBNB

7 PARTICIPATION REQUIREMENTS All full-time, actively at work employees are eligible for the plan. Employees must be actively at work to become insured. For the Employee Benefits Health Insurance Plan, dependants cannot join while in hospital. If the employer pays all of the cost, all eligible employees will be covered. If the employee contributes a portion of the cost, 75% of the eligible employees must enrol. The maximum insured age for employees and spouses is 65 and 19 for children (23 if full-time student). Evidence of insurability, at the employee s own expense, is required if enrolment is not made when first eligible and a medical examination may be required. EBNB