AIG GlobalHealth Expatriate Medical Insurance Member Guide

Transcription

1 AIG GlobalHealth Expatriate Medical Insurance Member Guide Important notes for using the Member Card: Use of the AIG GlobalHealth Member Card constitutes acceptance of the terms and conditions of this Member Guide and the policy. This Member Card is only valid for the period specified on the card. Before you can use the direct billing service with your Member Card, please ensure the following: You have paid your premium The qualifying period has expired. The participating status of the direct billing network provider may change from time to time without prior notice. Always verify a provider s participating status by calling our customer service officer at ; or referring to direct billing network provider (hereinafter network provider ) information published on our website About AIG American International Group, Inc. (AIG) is a leading international insurance organization serving customers in more than 130 countries and jurisdictions. AIG companies serve commercial, institutional, and individual customers through one of the most extensive worldwide property-casualty networks of any insurer. In addition, AIG companies are leading providers of life insurance and retirement services in the United States. AIG common stock is listed on the New York Stock Exchange and the Tokyo Stock Exchange. AIG Insurance Company China Limited (AIG China, formerly Chartis Insurance Company China Limited) is a China registered wholly owned property & casualty subsidiary of AIG, with branch offices in Beijing, Shanghai, Guangdong Province, Shenzhen and Jiangsu Province. With its long experience and comprehensive network, AIG China is now well positioned to capitalize on new opportunities arising form the increasing liberalization of the Chinese Market. This Member Guide is for reference only. For specific benefits, provisions and guidelines, please refer to your Benefit Schedule and the Policy document. This Member Guide is exclusively for the insured member of AIG GlobalHealth Expatriate Medical Plan and any unauthorized distribution is prohibited. 1

2 Table of contents Welcome Contact information for members General conditions Use of the AIG GlobalHealth Member Card My AIG GlobalHealth Account TRAVEL GUARD Usage of Enclosed Forms Claims Services a. Direct billing service i. Direct billing for outpatient service ii. Payment Guarantee for hospitalization, outpatient surgery and emergency hospitalization iii. Direct billing for dental and maternity Reimbursement claims a. Outpatient claims b. Accident or injury related claims c. Reporting period d. Other insurance Key Provisions a. Qualifying Period b. Waiting Period for Maternity c. 30-Day Free Look Privilege d. Routine Dental Treatment e. Major Restorative Dental Work f. EXCLUSIONS Important note 2

3 Welcome Welcome to the services provided by AIG Insurance Company China Limited. This Member Guide provides important member information such as usage of the AIG GlobalHealth Member Card, member contact information, medical benefit items, claims procedures including how to enjoy our direct billing services, how to lodge reimbursement claims and other general terms and conditions that members need to be aware of. Contact information for members We have a team of dedicated professionals to provide member services. The following contact information can be used for all AIG GlobalHealth member service related matters. AIG GlobalHealth hotline: ; (working hours) After hours and emergency: Travel Guard Fax: Globalhealth.sh@aig.com Branch Address: Shanghai branch 5F Chamtime International Financial Center 1589 Century Avenue, Pu Dong District Shanghai Guangdong branch: Units 5-12, 18/F, Dongzhao Commercial Center No.515 Dongfeng Zhong Road Guangzhou Shenzhen branch 11F Office Tower, Shun Hing Square, Diwang Commercial Center, 5002 Shennan Road East Shenzhen Beijing branch Units 15-16, 9/F, Building A, Hanwei Plaza No.7 Guanghua Road, Chaoyang District Beijing Jiangsu branch Units 3904, 39/F Sunny World Center, No. 188 Lushan Road, Jianye District Nanjing You can also visit our websites as below for product information and the latest Network Provider List. General Conditions Coverage for your medical plan is only applicable to service which are medically necessary and is subject to the terms, conditions, exclusions and limitations of the policy. It is also subject to the 30 day qualifying period (unless otherwise specified) and the settlement of premium required under the policy and the payment of deductible or co-payment specified for the service (if any). 3

4 Use of the AIG GlobalHealth Member Card As an insured member, you are required to show the AIG GlobalHealth Member Card each time before receiving services from network providers. Use of the Member Card constitutes acceptance of the terms and conditions of this Member Guide and the policy. You are responsible for verifying the participating status of the network provider which will be subject to change without prior notice. The insured member has the right to obtain an estimated cost for every medical service to be rendered by the network provider before taking any test or receiving any treatment. If any non-eligible expenses or expenses which exceed coverage incurred, you are required to settle the expenses at your own account with the network provider directly subject to the standard rates of the network provider. For reporting of lost card or request for card replacement, please call our AIG China customer service at ; , or notify us by fax The Member Card must be returned to your employer, if you are not insured under your company policy or, to AIG China upon termination of coverage, otherwise you may be held responsible for its improper use. The Member Card has the following information printed on front and back of the card: 4

5 My AIG GlobalHealth Account Having this access will allow you to readily obtain any information or documentation required and remain up to date on all developments in your account. Specifically you can access: - Claims: Members can check their claim status and view reimbursement details - Forms: All GlobalHealth forms are available to download in one convenient menu Web Service Registration Guide The registration process is simple and secure. Step1: Go to Click on Customer Service, and then click on the GlobalHealth Member Login Icon Step 2: Fill in address and Password which we provided in the letter with the Policy and click "Sign In. Travel Guard Travel Guard provides 24hr worldwide emergency assistance and travel convenience services for our members. Specifically, Travel Guard provides the following service benefits: Medical assistance including telephone medical advice, medical service provider referral, monitoring of medical condition during hospitalization, arrangement and payment of emergency medical evacuation and repatriation. Travel assistance including interpreter and legal referral services Claims assistance including information on claims procedure Please call for this service. Usage of Enclosed Forms Apart from this Member Guide, we also have sent you the following forms for your use throughout the policy year. Photocopies of these forms can be used. New Born Addition Complete this form after birth of your child in order for this child to be added to the policy coverage. Medical Claim Form Complete this form each time when you lodge a reimbursement claim. Make sure the claim form is completed by your physician for the following situations: Dental Claim Form Complete this form each time when you lodge a reimbursement claim for dental services. 5

6 Claims Services AIG GlobalHealth products provide free choice of medical providers for the insured persons on reimbursement basis, unless the Policyholder has selected at the placement of the Policy the use of the certificate of Social Insurance entitlement (including but not limited to Social Insurance card or Medicare Card) for such insured persons to register treatment in Medicare Approved Hospital in Mainland China only and use of Medicare Social Insurance as primary insurance cover for such treatment. For your convenience, we have established direct billing network with clinics and hospitals that are frequented by expatriate community in China. You will find the network provider list enclosed together with your Member Guide. You can also find the up-to-date network provider list on our website. a. Direct billing service i. Direct billing for outpatient service *Only apply to members on the following plans with nil deductible: Advantage 400 & Advantage 500. However, if the Policyholder who has selected at the placement of the plans eligible for direct billing service the use of the certificate of Social Insurance entitlement (including but not limited to Social Insurance card or Medicare Card) for you to register treatment in Medicare Approved Hospital in Mainland China only and use of Medicare Social Insurance as primary insurance cover for such treatment, then you could not enjoy direct billing service under such plan. Direct billing can be enjoyed by presentation of your Member Card at any of network direct billing partners. Please note, on your Member Card, if there is letter v printed on the front of your card, it means you have exclusion for a health condition, please do not use your card for treatment of this condition. Network provider will verify coverage with AIG China for direct billing service. ii. Payment Guarantee for hospitalization, outpatient surgery and emergency hospitalization Present Member Card at network provider for consultation Upon hospital admission assessed medically necessary by your attending physician, complete medical claim form and make sure the form is completed by the attending physician. Fax the claim form to AIG China for pre-authorization of direct billing. In emergency situations, your provider will arrange a pre-authorization with AIG China or through Travel Guard. 6

7 iii. Direct billing for dental and maternity Dental and maternity benefits have sub-limits and if you would like to enjoy our direct billing services, we will need to set them up for you. In this section we will explain how we may set up direct billing service for you. Before you decide to use direct billing for these services, we encourage you to choose your physician and experience their service for the first time on reimbursement basis. If the provider is one of our nominated direct billing providers and you are satisfied with the service quality, we will arrange direct settlement with your chosen provider for future visits. Please note, direct billing service will not be available once the member switched to other dental or maternity provider, reimbursement will base on usual submission procedure. However, if you decide to change to another direct billing provider, you will need to switch off current provider by informing us and restart steps for direct billing setup. Steps for setting up direct billing for dental Dental direct billing will be established once members satisfied the 3 months qualifying period for Routine Dental Treatment (where applicable) and 6 months for Major Restorative Dental Work (where applicable). However, Dental Examination and Dental Cleaning are not subject to the qualifying period. Members could enjoy the benefit for Dental Examination and Dental Cleaning at any time within the policy period by lodging the claims on reimbursement basis before qualifying period expired (where applicable). And the qualifying period (where applicable) would not apply again to the renewal policy year. Upon receipt of your request to establish direct billing service with a provider clinic, we will send you a letter to be authorized by you to stay with this doctor for future direct billing. Sign and return this letter to us by fax; and take the signed letter to this doctor in subsequent visit for direct billing. Steps for setting up direct billing for maternity Find a doctor of your choice that is within our direct billing network Pay your first fees and lodge claims to us (make sure your doctor has completed the medical claim form) Once we receive your claims, we will reimburse you for claims and send you a letter to be authorized by you to stay with this doctor for future direct billing. Sign and return this letter to us by fax; and take the signed letter to this doctor in subsequent visit for direct billing. 7

8 Reimbursement claims Except for our provider network for direct billing, all other claims are paid on reimbursement basis. To ensure you receive your claims as quickly as possible, it is important that you understand how to lodge claims correctly. a. Outpatient claims In order for claims to be considered, member should ensure that bills/receipts have the required information filled in by the doctor s office, laboratory, or pharmacy. The following is a summary of the basic details required: Name of the insured Date of treatment Doctor s name and professional qualifications Country where treatment took place The amount paid by the insured An explanation of the services rendered and the charge for each The diagnosis or other reason for the visit A laboratory and pharmacy bill should normally be submitted with the bill from the doctor who prescribed/ordered it. If not, the insured should submit a copy of the prescription, a doctor s report or a fully completed claim form showing the diagnosis and date(s) of treatment. b. Hospital/surgical claims Claims for surgery, or for treatment in a hospital, casually ward or emergency room, must be accompanied by a fully completed claim form. In case of hospitalization or surgery that is expected to result in bills exceeding US$2,500 then we may be able to assist you in settling hospital bills directly. Please fax us your completed medical claim form by your physician for authorization. For emergency hospital admission, please call Travel Guard on Clients requiring hospital guarantee should contact us as soon as the need for hospitalization/surgery arises. Both sufficient information and clear instructions as to what the member requires should be given to expedite handling of the request. In general, at least three (3) working days are required to arrange non-emergency hospital guarantee, particularly outside of Asia. Late or incomplete requests may affect our ability to provide service. For medical emergency, please refer to AIG Travel Guard Service Summary in the member kit. c. Accident or injury related claims The member should provide us with a statement giving full details of how the accident occurred (including date, time and place). We may also require other documentation, such as a police report. d. Reporting period Claims must be submitted within 90 days of the date of service unless it is shown that it was not reasonably possible to complete all claims document within this time. Complete claims documents not submitted within 12 months from the date of service will not be entertained under any circumstances. Offset of claims against premium will not be allowed. 8

9 e. Other insurance If you are insured by any other medical or accident insurance policy, you shall inform AIG China and provide us with a copy of the policy including the benefit schedules. We will treat the other plan as the primary carrier if: It is another medical plan, an accident or travel policy with medical benefit, or involves a third party s liability insurance policy. The illness, injury, or accident conforms to the type of risks assured by that plan The policy does not have a higher deductible than the AIG GlobalHealth plan, and The policy compensates for losses incurred, and is not of a type which pays a lump sum under certain circumstances (such as a disability, hospital cash, or dread-disease policy) If so, the bills should be submitted to the other insurer, who should pay up to its policy limits. If there are charges, or portions of charges, which remain unpaid, the insured should send them to us with: A full set of the original invoices, statement of accounts and official payment receipts issued by the medical services providers. A complete and duly endorsed AIG GlobalHealth plan claim form A policyholder, insured, or insured person should under no circumstance settle or waive any claim against a third party or other insurer. Doing so may jeopardize his or her right to claim under the AIG GlobalHealth plan. Key Provisions a. Qualifying Period Eligibility for benefits commences 30 days after an Insured Person has been included in this Policy, except when necessitated by a Bodily Injury occurring wholly after the Initial Effective Date of this insurance. No Qualifying Period will be applicable to renewal policies or to coverage for an Insured Person who was covered by a Preceding Policy. b. Waiting Period for Maternity Where maternity benefits are specifically provided for on the Benefits Schedule and only one Insured Person over the age of 19 is enrolled in the plan containing maternity benefits, the maternity benefits shall be limited to Covered Charges incurred 24 months after the Initial Effective Date. Where maternity benefits are specifically provided for on the Benefits Schedule and two or more Insured Persons over the age of 19 are enrolled in the plan containing maternity benefits, the maternity benefits shall be limited to Covered Charges incurred 12 months after the Initial Effective Date. c. 30-Day Free Look Privilege The Policyholder has 30 days from the initial receipt of the Policy (excluding any renewal thereof) to examine the terms and conditions of the Policy and may cancel the Policy within the foregoing 30-day period by written request to AIG China in which case premiums paid will be refunded. If the Policy is sent by post, it is deemed to have been delivered in the ordinary course of post. Where the Policy is so cancelled, AIG China shall have no liability whatsoever under the cancelled Policy and AIG China will be entitled to recover from the Policyholder any expense incurred by AIG China in underwriting the Policy. d. Routine Dental Treatment Where the qualifying period is applicable, costs incurred within 3 months from the Commencement Date of this option or Your Date of Entry, whichever is the later, are excluded except Examinations and Tooth cleaning. 9

10 e. Major Restorative Dental Work Where the qualifying period is applicable, costs incurred within 6 months from the Commencement Date of this option or Your Date of Entry, whichever is the later, are excluded. f. Exclusions: Please refer to the Policy Wording. All items under the policy exclusions and disability as specified by policy endorsement are not eligible for coverage. Please do not use the Member Card for these purposes. Important Note Please note that information about claims requirements and other insurance provisions is given for general guidance only. The member should refer to full terms, conditions and exclusions in the policy for a more detailed explanation. If there is any ambiguity between this brochure and the policy terms, conditions and exclusions then the latter shall prevail. 10