Group Health Insurance Policy Rider

Transcription

1 This document includes Schedule of Benefits and Endorsement to <Group Health Insurance Policy>. It is a part of the agreement between the Insurer and the Policyholder, and shall be read and understood together with <Group Health Insurance Policy>. In the event of any discrepancy, this document shall prevail. All other terms and conditions of the <Group Health Insurance Policy> remain in full force and effect. Policyholder: Dulwich International School Policy Year: August 1 st, 2016 July 31 st, 2017 Policy Type: International Plus Plan, Worldwide Plan Individual Annual Deductible: RMB 0 Family Annual Deductible (3 X Individual Annual Deductible): RMB 0 Per Claim Deductible: RMB 0 Policy Co-payment: 0% Policy Year Out-Of-Pocket Co-payment Maximum: No Maximum Optional Wellness Benefit: No, but screening of respiratory tract and vaccines are covered under Outpatient Benefit. Optional Group Dental Benefit: An annual checkup, simple fillings related to cavities or decay and root canal treatment, will be covered up to RMB 5,500 per person. (Dental cleaning is NOT covered). Optional Group Vision Benefit: No Optional War and Terrorism Benefit: No Extension Benefit: No Group Health Insurance Policy Rider 1. Underwriting and Waiting Period: A. For all Insured Persons accepted and enrolled as of August 1 st, 2016, and Insured Persons added in the middle of the Policy Year, Pre-existing Conditions are covered without a waiting period. B. For all persons accepted and added in the middle of the Policy Year, Pre-existing Conditions are covered without a waiting period. C. The requirement for newly hired employees in the middle of the policy year to present credible coverage is waived. D. There will be a 12 months waiting period for Maternity Related Benefits for newly added members (including employees and spouses). 2. Hospital accommodations will be covered up to standard private room anywhere within the covered area. 3. The RMB 60,000 annual limit on coverage for Congenital Conditions and Birth Anomalies does not apply. 4. Maternity benefits are capped at RMB 64,000 per pregnancy under this policy including prenatal check, normal delivery and postnatal check. 5. Complications of pregnancy refer to the following conditions that arise during the antenatal stages of pregnancy: ectopic pregnancy, miscarriage, stillbirth and hydatidiform mole, will be covered up to RMB 250, Complications of childbirth refer to the following conditions that arise during childbirth that require a recognized obstetric procedure: post-partum hemorrhage, retained placental membrane and medically necessary caesarean sections will be covered up to RMB 150,000. 1

2 7. Definition of Emergency coverage in US under International Plus Plan will be revised from current term as of : For a claim to be payable under the emergency coverage provided under the International Plus Plan, it must be a sudden or unexpected onset of a condition requiring medical or surgical care which the Insured Person secures after the onset of such condition (or as soon thereafter as care can be made available, but in any case not any later than twenty-four (24) hours after the onset), and in the absence of which an Insured Person would be expected to suffer severe life-long injury or premature death. to Emergency outside of geographic coverage: treatment which is medically necessary to prevent the immediate and significant effects of illnesses, injuries or conditions which if left untreated could result in a significant deterioration in health. Only medical treatment through a physician, specialist or medical practitioner and hospitalization that commences within 24 hours of the emergency event will be covered.. This can be applied to Dulwich schools in other countries like Singapore and Korea as well. 8. Regarding the USA Pharmacy Network, members with coverage limitations on Pre-existing Conditions will not have access to the USA Pharmacy Network. Members should pay upfront and then submit a claim for reimbursement. If covered, reimbursement will be 100% less the Formulary Co-payment. 9. According to the Usual and Customary guideline, this policy does not provide full reimbursement for covered medical treatment at the following facilities. For International Plus Plan and Worldwide Plan members, an additional 20% co-payment will apply for Outpatient treatment when use of the providers listed below. This can also apply to other similarly priced medical facilities. Please refer to your Direct Billing Providers List for the availability of direct billing providers for your plan, as well as specific terms related to the use of direct billing services at particular providers. United Family Hospitals and Clinics (Beijing, Shanghai, and other cities if any) ParkwayHealth Clinics / Gleneagles International Medical & Surgical Center (All cities except Beijing and Hong Kong) Shanghai East International Medical Center Raffles Medical, formerly International SOS Clinics (Beijing, Tianjin, Nanjing, Shenzhen and other cities if any) Hong Kong Adventist Hospital Matilda International Hospital (Hong Kong) Hong Kong Sanatorium & Hospital Mount Elizabeth Hospital (Singapore) Gleneagles Hospital (Singapore) For all members, the Insurer will not accept claims for treatment received at the following providers, or from physicians affiliated with such providers: Asia Medical Specialists / Sportsphysicians (Sportsperformance Ltd.). 2

3 Schedule of Benefits Unit: RMB per Insured Person per Policy Year, unless stated otherwise. Lifetime & Annual Maximums Overall Policy Year Maximum per Insured Person RMB 12,500,000 Overall Inpatient Maximum Up to Overall Policy Year Maximum Overall Outpatient Maximum Up to Overall Policy Year Maximum Overall Lifetime Maximum per Insured Person None Congenital Conditions, Birth Anomalies (subject to Overall Inpatient Maximum or Overall Outpatient Maximum) All treatment costs for Congenital Conditions or birth anomalies Covered up to Overall Policy Year Maximum Chronic Conditions (subject to Overall Inpatient Maximum or Overall Outpatient Maximum) All treatment costs for Chronic Conditions Covered up to Overall Policy Year Maximum Catastrophic Illnesses, as defined in the Policy Catastrophic Illnesses (subject to Overall Inpatient Maximum or Overall Outpatient Maximum) AIDS/HIV Sexually Transmitted Diseases including AIDS and all diseases caused by and/or related to the HIV virus Covered up to Overall Policy Year Maximum Covered up to Overall Policy Year Maximum if not pre-existing Hospitalization and Inpatient Benefits (Pre-authorization is required) (subject to Overall Inpatient Maximum) Standard private room (suite room is not included) in coverage area Meals Companion Bed (see Policy for age limits) Intensive Care, Cardiac Units Nursing Care Medical treatment, drugs, medications, laboratory, x-rays, diagnostic procedures and tests, biological anesthesia and oxygen services, blood products and their administration, dressings Radiation therapy, inhalation therapy, respiratory therapy, chemotherapy, physical and occupational therapy Video Laryngoscope Inpatient Consultation by a Physician or Specialist Operating room and recovery room Inpatient Surgery Inpatient Surgeon & any Assistant Surgeon Anesthesiologist & any secondary assistants Medical Emergency Services Emergency Room (if leads to Hospital Admission) Day-care Treatment As per Hospitalization and Inpatient benefits, received as a Daycare patient. Extended Care Facility, Skilled Nursing, and Inpatient Rehabilitation Must be confined to facility immediately following or in lieu of a Hospital stay Transplant Services Medically Necessary human organ, blood, bone marrow, stem cell transplants, and other similar procedures Expenses for Donor, Donor search, and transplant tissue fees are not covered. Mental Health as an Inpatient Psychotherapeutic treatment and psychiatric counseling and treatment in a Hospital or approved facility; Bulimia, anorexia, Bereavement, non-medical causes of insomnia, ADD, and ADHD (for the patient only) Up to 90 days per episode Covered RMB 50,000 3

4 are covered conditions. Inpatient rehabilitation treatment for alcohol and drug abuse Hospice Care (Inpatient basis) RMB 20,000 (maximum is for Outpatient and Inpatient rehabilitation treatment combined) (Preauthorization required) 45 days Durable Medical Equipment Purchase, Rental Up to Purchase Price (as described in the Policy); Repairs or replacements for Durable Medical Equipment originally obtained under this Policy. Emergency Medical Evacuation (see Policy for details) Included Accompanying person during Medical Evacuation (see Policy for details) Included Hotel fees for the accompanying person RMB 800 per night, not to exceed 12 nights per Policy Year Outpatient Benefits (subject to Overall Outpatient Maximum) Emergency Room (if leads to treatment as an Outpatient) Medical Emergency Services Outpatient Physician Visit/Consultation by Specialist Echocardiography, Ultrasound, CAT Scan, PET Scan or MRI, X-Rays Endoscopy (e.g., gastroscopy, colonoscopy, cystoscopy) Laboratory Chemotherapy, Radiotherapy, Radiation Therapy, Respiratory Therapy (Pre-authorization required) Outpatient or Ambulatory Surgery Outpatient Surgeon & Assistant Surgeon Outpatient Anesthesiologist & any secondary assistants Outpatient Prescription Drugs - Outside of the U.S., and up to 90-day supply per Outpatient Prescription Drugs - In the U.S. (For Worldwide Plan only) Prescribed Traditional Chinese Medicine (Exclusions - Chinese traditional medicine for general health improvement and Chinese herbal pastes) Therapeutic Services Physical Therapy, Physiotherapy, Chiropractic Therapy, Vocational Therapy, Speech Therapy, Occupational Therapy Alternative Medicine Homeopathy and Acupuncture treatment for a covered Illness Sleep Studies/Tests and Treatment for suspected conditions of Narcolepsy or Obstructive Sleep Apnea Mental Health Outpatient Psychotherapeutic treatment and psychiatric counseling and treatment; Bulimia, anorexia, Bereavement, non-medical causes of insomnia, ADD, and ADHD are covered conditions Outpatient Rehabilitation treatment for alcohol and drug abuse filling In-network: no separate limit Out-of-network: 80% reimbursement Up to 180-day supply per filling 100% outside of Mainland China; 100% at First, Second, and Third Grade Non-Profit Hospitals as defined by the Ministry of Health in Mainland China; Other Providers within Mainland China: RMB 300 medication fee per visit, 20 visits RMB 40,000 (combined) RMB 4,000 Covered (Pre-authorization required) Fully Covered (up to 20 visits per year). Combined with below related benefits: 1. Outpatient prescribed drugs limitation (per refill will be counted as one visit) 2. Therapy benefit (max. 40,000 RMB) RMB 20,000 (maximum is for Outpatient and Inpatient rehabilitation treatment combined, and is subject to the sub limits of Mental Health Outpatient/Inpatient) (Pre-authorization required) Hospice Care (outpatient basis) RMB 40,000 Private Duty Nursing, Skilled Nursing, Visiting Nurse, Home Health Nursing 100 days (Pre-authorization required) 4

5 Visiting Nurse Home Health Care Durable Medical Equipment Purchase, Rental Up to Purchase Price (as described in the Policy); Repairs or replacements for Durable Medical Equipment originally obtained under this Policy; Insulin pumps, glucose test strips, and other Medically Necessary diabetic supplies are also included in coverage. Ground Ambulance Emergency Dental treatment Emergency treatment to restore or replace sound, natural teeth damaged in an Accident. Initial treatment must be obtained within 30 days of the Accident. Examinations/Screenings Benefits Papanicolaou Screening (PAP) and routine mammogram, including consultation fees PSA exam, including consultation fees (Pre-authorization required) RMB 40,000 including costs that carry over into the next Policy Year, if any (Pre-authorization required) One each per Policy Year One per Policy Year Screenings recommended by a physician due to family medical RMB 2,000 history Maternity Related Benefits (Pre-authorization is required for baby delivery) (After 12-month waiting period for newly added Employee or Spouse) (NOT subject to Overall Outpatient Maximum and Overall Inpatient Maximum, unless specified otherwise) Benefit is for Insured Employee, spouse or domestic partner. Dependent Daughters are not covered. Please refer to the Maternity Related Services section of the Policy for details. Prenatal care, normal delivery and postnatal care RMB 64,000 maximum per pregnancy Maternity for Dependent daughters are not covered Complications of Pregnancy Complications of pregnancy refers to the following conditions that Covered up to RMB 250,000 arise during the antenatal stages of pregnancy: ectopic pregnancy, miscarriage, stillbirth and hydatidiform mole Complications of childbirth Complications of childbirth refers to the following conditions that arise during childbirth that require a recognized obstetric Covered up to RMB 150,000 procedure: post-partum hemorrhage and retained placental membrane; complications of childbirth shall also refer to medically necessary caesarean sections Newborn Infant Care Services - nursery services and medical care Covered up to Overall Outpatient or Inpatient during first fourteen (14) days of life Maximums Well Baby Care: includes child immunizations and routine medical exams. Covered immunizations include diphtheria, hepatitis B, Covered during first 12 months of life and limited measles, mumps, pertussis, polio, rubella, tetanus, varicella, to 6 routine medical exams (baby must be enrolled haemophilus influenza B, hepatitis A and other Medically as an Insured Dependent) Necessary pediatric immunizations (not subject to 12-month waiting period) Repatriation of Mortal Remains or Local Burial (NOT subject to Overall Inpatient Maximum or Overall Outpatient Maximum) Local Burial Repatriation (between Countries) of Mortal Remains RMB 160,000 Death must occur within the areas of coverage of your Policy Repatriate to all countries; 5

6 OPTIONAL BENEFITS War and Terrorism Benefit (Medical treatment subject to Deductible and Policy Co-payment for health plan) (Medical treatment subject to Overall Inpatient Maximum or Overall Outpatient Maximum) NO Wellness Benefits (Not subject to Deductible and Policy Co-payment for health plan) (Not subject to Overall Outpatient Maximum) NO, but screening of respiratory tract and vaccines are fully covered. Dental Benefits (Not subject to Deductible and Policy Co-payment for health plan) (Not subject to Overall Outpatient Maximum) Vision Benefits (Not subject to Deductible and Policy Co-payment for health plan) (Not subject to Overall Outpatient Maximum) One annual checkup, simple fillings related to cavities or decay and root canal treatment, will be covered up to RMB 5,500 per person. (Dental cleaning is NOT covered). NO Service Provider: MSH CHINA Enterprise Services Co., Ltd 5th Floor, North Tower, Building 9, Lujiazui Software Park, No. 20, Lane 91, E Shan Road, Pudong, Shanghai, P.R.C Tel: Fax: