02 Our Advantage 我们的优势 Key Benefits of Comprehensive Coverage* * 全面的医疗福利和健康保障 Annual Maximum: 1,000,000 per covered person per year 高保额 : 每人每年 1 百万人民币

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1 01 Company Introduction 公司简介 永诚财产保险股份有限公司 ( 以下简称永诚保险 ) 成立于 2004 年, 是由国内外实力雄厚的大型电力企业集团和产业投资集团共同发起组建的全国性股份制财产保险公司, 总部设于上海, 目前注册资本金 亿元人民币, 拥有 33 家省级分公司 240 余家中心支公司及营销服务部, 员工超过 5000 人, 形成了完善的全国性服务网络 目前, 永诚保险为电力 石油 煤炭 公共基础设施建设 船舶航运等领域的企业提供了专业 全面的风险控制服务 同时, 永诚保险推出的车险 健康险 互联网保险等产品, 也获得了广大保险消费者的欢迎和肯定 2015 年, 凭借近年来优异的价值成长和优良的品牌形象, 永诚保险获评 中国价值成长性十佳财险公司 与此同时, 永诚保险还积极投身社会公益事业, 先后出资捐建四川省彭州市通济镇思文永诚中心小学 陕西省汉中市王家岭永诚保险希望小学 2015 年, 与中国妇女发展基金会共同发起创建 母亲健康护航行动 母亲健康保险基金, 为贫困母亲提供重大疾病意外伤害保险, 并首批出资 1000 万元用于基金平台的建设 永诚保险将继续以市场为导向, 走创新差异化的发展道路, 追求有质量的发展, 有效益的增长 我们的核心价值理念 : 诚信 专业 效率 和谐 Alltrust Insurance Company of China Limited (hereinafter referred to as AIC, or Alltrust, or the Company) is a nationwide shareholding property insurance company jointly founded by a few large-scale power conglomerates and industrial investment groups both in China and abroad in Headquartered in Shanghai, it currently boasts a registered capital of RMB billion and a nationwide service network with 33 provincial branches and more than 240 central sub-branches and sales offices, a workforce of more than 5000 people. Currently, AIC could facilitate enterprises to conduct professional and complete risk management from power generation, petroleum and coal to public infrastructure, shipbuilding and shipping, etc. Meanwhile, its products of motor insurance, health insurance and internet insurance have all won recognition and popularity among consumers. Thanks to its outstanding growth in value and impressive branding image, Alltrust was praised as one of the Top Ten Most Valuable Growth P&C Companies in China in In the meantime, AIC has always been proactive taking part in the cause of social welfare. It has donated to build the Siwen Alltrust Central Elementary School in Tongji Town of Sichuan Province and Wangjialing Alltrust Insurance Hope Elementary School of Shanxi Province. In cooperation with China Women s Development Foundation, AIC launched Mothers Health Insurance Fund An Initiative to Safeguard Mothers Health in 2015, and donated RMB 10 million as the startup capital for the fund which is dedicated to providing critical illness insurance and accidental injury insurance for poverty-stricken mothers. AIC will continue to take a market-oriented, innovation-driven and differentiated approach to development in pursuit of quality and effective growth. Our core value notions : Integrity, Professionalism, Efficiency and Harmony. 1

2 02 Our Advantage 我们的优势 Key Benefits of Comprehensive Coverage* * 全面的医疗福利和健康保障 Annual Maximum: 1,000,000 per covered person per year 高保额 : 每人每年 1 百万人民币 Including outpatient, inpatient and emergency medical coverage 主险包括门诊, 住院, 紧急医疗等 Optional maternity 可选生育福利 24/7 global access & support through GBG Assist 24/7 GBG 援助中心提供全球救援服务 State-of-the-art Customer Service 卓越的客户服务 Convenience of cashless direct billing service, the hospital directly bills the insurance company 便捷的免现金直付服务 保险公司与医院直接结算 Smart-card technology for instant claims adjudication at direct bill providers 中国直付网络医疗机构采用即时理赔的智能卡技术 24/7 hotline for customer service with multiple languages 24 小时多语言客服热线 Web-based look-up of claims status 提供网上自助查询功能 More than 1,800 direct billing health providers in China ** 遍布中国 1,800 多家直付医疗机构 ** Over 560,000 direct billing health providers around the world ** 遍布全球各地的 560,000 多家直付医疗机构 ** * Please see this proposal for benefits details 福利详情请参见本计划书 ** Direct billing service is available contracted direct billing health providers only 仅在直付医疗机构可享受直付服务 2

3 03 Geographic Coverages 地域保障范围 Geographic Coverages 可选地域保障范围 Greater China Coverage 大中华保障 Full coverage up to Usual and Customary Charges in Mainland China, Taiwan, Macao and Hong Kong only 保险人对被保险人在中国大陆, 香港, 澳门以及台湾地区发生的符合通常惯例水平的医疗费用提 供保险保障 No coverage outside of Mainland China, Taiwan, Macao and Hong Kong under any conditions 上述地区以外的任何地区发生的任何医疗费用均不提供保障 Greater China Plus Coverage 大中华增强保障 Full coverage up to Usual and Customary Charges in Mainland China, Taiwan, Macao and Hong Kong 保险人对被保险人涵盖在中国大陆 香港 澳门和台湾地区发生的符合通常惯例水平的医疗费用提供保险保障 Other areas are deemed restricted areas, where only emergency coverage is covered up to 200,000 上述地区以外任何国家和地区紧急情况下的医疗费用, 紧急医疗费用最高保额为 200,000 Emergency treatment is defined in the policy and must be approved by our Care Coordination Company 紧急医疗必须得到我们的医疗协助机构的认可 Mainland China Coverage 中国大陆保障 Full coverage up to Usual and Customary Charges in Mainland China only 保险人对被保险人在中国大陆发生的符合通常惯例水平的医疗费用提供保险保障 No coverage outside of Mainland China under any conditions 中国大陆外的任何地区发生的任何医疗费用均不提供保障 3

4 04 Schedule of Benefits 保障福利表 The same Schedule of Benefits will apply to all plans unless indicated otherwise. 除备注说明以外, 下列保险福利适用所有保险计划 Maximum benefits are per person per policy year unless indicated otherwise. 除备注说明以外, 限额均指每一被保险人每保单年度的赔付上限 Policy Period: One Year 保险期限 : 一年 Currency: CNY( ) 币种 : 人民币 ( 元 ) Pre-authorization is required for the certain procedures, Please see the details on page 13 针对某些特殊的治疗项目需要 事先授权, 详情请参见第 13 页 Lifetime & Annual Maximum, Annual Deductible and Co-payment 终身与年度最高保额, 年免赔额及自付比例 Annual Maximum Per Covered Person 年度最高保额 ( 每一被保险人 ) Lifetime Maximum 终身保额限制 Individual Annual Deductible 个人年免赔额 Family Annual Deductible 3 times of Individual Annual Deductible 家庭年免赔额 -- 个人年免赔额的三倍 Provider Co-payment Provider Co-payment refers to co-payment for Tier 1 providers (Luxury Providers). Please refer to Note 2 on Appendix II (page 15) for a complete list of Tier 1 providers in detail. 通常惯例自付比例通常惯例自付比例是指针对一级医疗供应商 ( 即昂贵医院 ) 的自付比例 详情请见附页二备注二 ( 第 15 页 ), 完整的一级医疗供应商列表 Policy Co-payment 保单自付比例 1,000,000 No limit 无限制 % 0% Inpatient Benefit(Pre-authorization is required for inpatient treatment) 住院治疗 ( 住院治疗需事先授权 ) Intensive Care Unit and Theatre Costs (medically necessary) 重症监护病房费 ( 医疗必须 ) Inpatient Surgery 住院手术费 Accommodations Standard semi-private room (standard private room if in Mainland China s public hospital) 住院食宿费限标准双人病房 ( 中国大陆地区公立医院可享受标准单人病房 ) Companion Bed For a parent accompanying a hospitalized insured child under 18 years of age and for a baby aged under 16 weeks accompanying a hospitalized female insured person 陪床费未满十八周岁的附属被保险人住院期间其一父 / 母亲陪同住院加床费, 女性被保险人住院期间其出生不满十六周的新生婴儿住院加床费 Doctor s Fees, Surgeon s Fees, Anesthesiologist s Fees 医师诊疗费 手术医师费和麻醉师费 4

5 05 Schedule of Benefits 保障福利表 Nursing Fees and Ancillary Fees 护士护理费 Therapy and Treatment Consultations, pathology and radiology 治疗费 会诊咨询和病理学分析等 X-rays, Diagnostic Tests and Procedures X 光线费, 诊断性检查费 MRI, PET, CT Scans and Oncology Tests 核磁共振检查, 正电子发射断层扫描, 计算机体层摄影扫描, 肿瘤测试 Drugs and Dressings 住院药品费和手术敷料费 Reconstructive Surgery Following an accident or following surgery for an eligible medical condition 矫形改造手术费 仅限于遭受意外伤害或患疾病需要接受矫形改造手术恢复肢体功能或容貌的情况 Extended Care / Inpatient Rehabilitation Skilled nursing and related services on an inpatient basis for patients who require medical or nursing care for a covered illness 康复治疗和专业护理费 仅限于住院情况下对于可保疾病医学必需的康复治疗和专业护士实施的专业护理和相关服务 Hospital Cash 住院津贴 A cash payment will be made to the beneficiary when they: - received treatment in hospital which is covered under this plan - received an inpatient treatment - no cost will be submitted to us for claims 在满足以下条件基础上您将得到住院津贴 : - 您所接受的治疗在本合同责任规定范围内 - 住院治疗需过夜 - 住院产生的所有费用不向本保险公司进行索赔 Covered up to 90 days, 累计以 90 天为上 限 Covered up to 800 per night, up to 20 nights 最高限额 800 元 / 天, 累计以 20 天为上限 * All the Inpatient Benefits Maximums shown above also apply to the correspondent Outpatient Benefits * 以上所列各项住院福利限额也适用于相对应的门诊福利 5

6 06 Schedule of Benefits 保障福利表 Outpatient Benefit 门诊福利 Doctor s Fees, Specialist s Fees 医师诊疗费和专家门诊费 Prescription Drugs OTC (Over the counter) is covered only in Greater China when it is prescribed by a licensed physician as treatment of a covered illness or injury. 处方药费由执业医生对于可保疾病开据的治疗性非处方药仅在大中华地区涵盖 Laboratory Tests, X-rays, Diagnostic Tests and Procedures 化验费和检查费,X 光线费 Outpatient Surgical Operations 门诊手术费 Emergency Room 急诊室费 Homeopathy and Chinese Medical Treatment Include consulting fee, acupuncture treatment, Chinese herbal medicine and other medical necessary treatment for a covered illness 为可保疾病施行的顺势疗法和中医治疗包括诊疗费, 针灸, 中草药及其他医疗必需的治疗 Sleep Testing and Treatment(Pre-authorization required) For the suspected conditions of Narcolepsy or Obstructive Sleep Apnea 睡眠检查和治疗费 ( 需事先授权 ) 发作性睡眠或阻塞性呼吸暂停症状的检查和治疗费 Durable Medical Equipment Purchase or rental; Rental up to Purchase Price 耐用医疗设备 购买或租借费 ; 租借费用最高以购置费用为限 Covered up to 30,000** 最高限额 :30,000 元 ** Covered up to 300 per visit, up to 6 visits 300 元 / 次, 累计以 6 次为上限 ** The 30,000 Outpatient Limit applies to all the outpatient treatment and outpatient related cost. ** 30,000 元门诊福利年限额适用于所有门诊及门诊相关治疗 6

7 07 Schedule of Benefits 保障福利表 Special Conditions 特殊疾病治疗 Sexually transmitted diseases and all related conditions 性传播疾病和所有相关症状 Treatment available if condition is not pre-existing 治疗仅限非既往症的情形 Major Organ Failure or Transplant Expenses for donor and transplant tissue storage fees are not covered 重要器官衰竭或移植 责任免除 : 器官移植供体的相关费用以及器官储藏费用 Chronic Conditions 慢性病 For Chronic Conditions diagnosed within 180 days after the start date of cover, full details are required before benefits are payable 对于生效日后 180 天内确诊的慢性病的客户需提供详细的信息 Maintenance and palliative treatment 医学必需的维护, 缓解或对症治疗等 Stabilization of acute exacerbations of chronic conditions 慢性病急性恶化的稳定治疗 Mental Health 精神疾病 Including Radiotherapy, Chemotherapy 放射线疗法 化学疗法 Hospice Care 临终关怀 Covered up to lifetime maximum of 500,000 终身累计最高限额 500,000 元 Covered up to 5 visits for outpatient 20,000 per policy year 200,000 Lifetime Maximum 门诊累计以 5 次为上限每一保险年度最高限额 20,000 元终身累计最高限额 200,000 元 and not subject to Outpatient Annual Maximum 且不受限于门诊 年限额 Covered up to 45 days for inpatient 最高涵盖住院 45 天 7

8 08 Schedule of Benefits 保障福利表 Emergency Evacuation 紧急医疗转运 Ground Ambulance (Resulting an Inpatient Hospitalization) 救护车 ( 并在救护车转运后即刻接受住院治疗 ) Air Ambulance(Pre-Authorization Required) Economy-class air tickets for an accompanying person, in the case of initial transportation to the location of the insured person Economy-class air tickets to return to the place of residence for the insured person and the accompanying person 空中转运 ( 需事先授权 ) 承担一位陪同人员赶往事发地点时的初始公共交通工具费 ( 飞机限经济舱 ), 承担被保险人和一位陪同人员在被保险人治疗完成或病情稳定后返回常住地的公共交通工具费 ( 飞机限经济舱 ) Maternity Benefit*** (Optional) --12-month Waiting Period 可选生育福利 ***( 可选 )--12 个月等待期 Maternity Prenatal care (including two times ultrasound), premature delivery, normal delivery or medically necessary C-section, postnatal care and complications of pregnancy Maternity Benefits for dependent daughters are not covered 生育产前检查 ( 包含两次 B 超 ) 早产 顺产 医学必需的剖腹产 产后复查费和妊娠并发症治疗等 责任免除 : 作为子女的附属被保险人的生育福利 Infant Care(Only to Infants Born of a Covered Pregnancy) for the first 14 days without notification; Covered after enrollment subject to the satisfaction of the Policy Year Deductible and Co-payment amounts in accordance with the Policy and the Schedule of Benefits 新生婴儿护理 ( 仅限于保单承担保险责任的生育项下出生的婴儿 ) 婴儿出生后 14 天内免告知 婴儿入保后按照保单保障福利进行理赔 免赔额以及自付比例均按照保单保障福利 22,400 per pregnancy 每次怀孕最高理赔 22,400 元 8

9 09 Claim Services 理赔服务 Claims Service (ICS), prides itself on timely and responsive customer service. Our members find that utilizing their health insurance coverage is easy to use because of two key components a worldwide network of medical facilities that bills us directly for services rendered, and an online website that allows for easy filing of claims from non-network facilities.* 高端医疗保险最重要的是理赔款的支付 在这一方面, 我们的 国际理赔服务中心 ( 简称 ICS ) 以迅速精准的客户服务而著称 我们的客户会觉得使用高端医疗保险是如此地简单 这是因为我们不仅能在世界各地的网络医疗机构为客户提供的直付服务, 即使在网络外也可以轻松在网上填写理理赔表格来申请理赔 When a network facility is not available, which usually happens only outside of the United States, members pay for their treatment at the time of service and then file their claims. Because of our vast experience in the international marketplace, GBG has developed an expertise in handling banking and currency requirements in jurisdictions around the world. There are three ways to receive reimbursement on claims incurred outside of the network facilities: 当无法使用直付医疗网络时 ( 通常在美国境外 ), 被保险人可以在治疗时先付款然后申请理赔 凭借在国际市场上的丰富经验, 我们也非常擅长在不同国家和地区处理相关的银行及货币事物 我们对直付医疗网络外的理赔款支付有以下三种方式 : 1) Electronic transfer 电子转帐 Reimbursements are deposited to your Mainland China or U.S.-based bank and checking account. This method offers instant transfer of funds with no fees applied to transfers. This method is only available to holders of Mainland China or U.S. bank accounts. 理赔款直接存入您在中国大陆或美国的银行及支票账户 这种即时转帐方式不会产生额外手续费, 但仅限于中国大陆或美国境内的银行账户 2)Wire transfer 电汇 Reimbursements are delivered by wire transfer directly to a non-mainland China/U.S. bank account. Instant transfer of claims reimbursements, easy to set-up and withdraw money. There is no transfer fee applied by us. This method is subject to data and transmission errors; to additional fees by receiving and/or intermediary financial institutions; and to the rate of exchange. 理赔款通过电汇的方式存入非中国大陆或美国的银行账户 此即时汇款方式操作简易且便于取现 尽管我们不收取转账费用, 但可能产生数据和传输错误, 汇率差以及由收款行或中间行收取的额外手续费 3)Payment by check 支票 Reimbursement is a check payable to the member and mailed to the member s home or work location. Simple to issue and deposit, checks are recognized globally and payment can be stopped if misplaced or diverted. Be aware, however, checks can be lost or misplaced or may be subject to holds and to check cashing fees by some institutions. 理赔款以支票的形式寄到被保险人的工作或家庭地址 支票便于兑换和储存, 如果支票寄错了或者付款转移了, 支票能被广泛地识别并取消 但是需注意的是支票有可能会遗失或寄送到错误地址, 或在支取时被一些金融机构收取额外费用 9

10 10 GBG Assist and Medical Network GBG 援助中心及医疗网络 Over the last few years, GBG Assist has expanded our global medical network, particularly outside the U.S. With over $1 billion in annual worldwide healthcare, we have combined our overall purchasing power in order to enhance our network for our clients. 近年来,GBG 援助中心不断地开拓全球网络医疗网络, 特别是在美国以外的地区 每年我们在全球健保上的投入超过十亿美元, 通过增强医疗网络实力, 以求更好的服务于客户 GBG Assist is a phone call away, 24/7, 365 days a year, to service your needs and guide you in the right direction. GBG 援助中心提供 24 小时全年无休的热线电话服务, 满足您的需求并寄予正确的指引 KEY CONTACT INFORMATION 重要信息联系 For routine inquiries, Emergency Medical Assistance and Pre-Authorization: 用于常规咨询服务, 紧急医疗援助和事先授权 US Toll Free 美国 : Worldwide Collect 其他地区 : Website 网址 : Emergency Medical Assistance 紧急医疗救助 Security Assistance 安全援助 Access to 24/7 security Assistance center 24/7 安全援助中心 Preferred Provider Network 首选医疗网络 World Medical Network 全球医疗网络 World Medical Network has built one of the most comprehensive direct-bill provider networks in the world and serves as a core benefit to GBG products and services. These facilities not only provide the finest care available in the local environment, but they have been chosen for their expertise in dealing with expatriates. In addition, all network providers will bill GBG directly; eliminating the need for member to copy bills, file claims forms, and wait for reimbursement. 作为 GBG 产品及服务的核心部分, 全球医疗网络是世界上覆盖面最广的直付医疗网络之一 这些医疗服务机构不仅能在当地环境提供最好的医疗护理, 并且专业为外籍人士服务 另外, 所有的网络医疗供应商都将直接与 GBG 进行医疗费用结算 ; 为被保险人免去了复印账单 准备理赔表格 等待偿还款的流程 *Only for outside Greater China, Some online service may be restricted by the local laws and regulations * 部分网上功能可能因为当地法律法规有所限制 10

11 11 Medical Network 医疗网络 China Provider Network 中国医疗网络 In China, GBG uses a unique combination of GBG s World Medical Network and Medilink s POS provider network and care management services to provide seamless claims processing for direct billing providers. In addition, we use Medilink s exclusive POS card technology to achieve instant claims processing; this real-time claim adjudication system provides a great convenience to our clients. 在中国, 我们采用了 GBG 全球医疗网络 中间带和健康管理服务相结合的独特的方式实现了医疗理赔处理直付服务的无缝连接 并且, 我们采用中间带独一无二的 POS 卡技术以达到即时的理赔处理, 这种实时理赔决断系统为我们的客户提供了极大的便利 North America Provider Network 北美医疗网络 In the United States, we utilize Aetna as its Preferred Provider Network. Aetna is one of the premier PPO Network that includes more than 5,300 hospitals and 561,000 professional providers in the United States. The network has coverage in all 50 states plus the District of Columbia. 在美国, 我们使用 Aetna 作为首选医疗服务网络 Aetna 是美国最优质的医疗服务网络之一, 覆盖超过 5,300 家医院和 561,000 家专业医疗服务供应商, 范围涵盖全美 50 个州及首都华盛顿 ( 哥伦比亚特区 ) Key Direct-Billing Providers in Greater China * * 大中华地区主要直付网络医院 1. Peking Union Medical College Hospital International Medical Service 北京协和医院国际医疗部 2. China-Japan Friendship Hospital International Department 中日友好医院国际医疗部 3. General Hospital of Beijing PLA Military Region, Foreigner s Wing 北京军区总医院特需医疗部 4. Huashan Worldwide Medical Center 上海复旦大学华山医院涉外医疗中心 5. Shanghai Ruijin Hospital VIP Clinic 上海瑞金医院特需门诊部 6. Shanghai Children's Medical Center 上海交通大学医学院附属上海儿童医学中心特诊部 7. Hua Dong Hospital Special Medical Center 复旦大学附属华东医院特需门诊部 8. Guangdong Concord Medical Centre 广东协和高级医疗中心 9. Clifford Hospital Of Guangzhou University of TCM VIP center 广州中医药大学祈福医院 VIP 中心 * You can send to aicservice@gbg.com to obtain Direct-Billing Provider List in Greater China. * 您可以通过发送邮件至 aicservice@gbg.com 获取大中华直付网络医院列表 11

12 12 Direct Billing in China 中国境内直付流程 Outpatient Direct Billing Procedures - 门诊医疗直付流程 Registration Counter 登记处 Direct-Billing Card Sample 保险直付卡卡样 Payment 支付 Filling Outpatient Claim Form/Diagnose Treatment 填写门诊理赔申请表 / 诊断 / 治疗 Please sign here 请在此处签名 Dispensing 药品分发 Inpatient Direct Billing Procedures 住院医疗直付流程 Diagnosis Review GBG/ 中间带 诊断回顾 Coverage Confirmation Pre-discharge 保险责任确认 Assessment/Adjudication Discharge 保险责任确认 出院 * Direct billing procedure might vary in different regions, please check insurance instructions or contact us for more information * 在不同地区的网络医疗机构直付流程可能略有不同, 请查阅保险使用说明或拨打我们的客服热线获取详情 12

13 13 Pre-Authorization 关于事先授权 All members must receive pre-authorization prior to undergoing certain procedures/treatments listed below. Pre-Authorization provides assurance they will be reimbursed for expenses incurred from pre-authorized medical treatment, and confirms in advance that the procedure/treatment will be covered under their policy. Members that fail to obtain pre-authorization prior to treatment may be held liable for paying an additional co-pay of up to 40% of the entire cost of the procedure. The Insurer reserves the rights of not taking responsibility for reimbursement. 在接受以下列表中任何一项治疗或医疗项目之前, 所有客户都必须获得事先授权 客户必须核实相关的医疗费用能得到赔付, 而且在治疗之前确认他们的保险能理赔这些费用 治疗之前未获得事先授权, 客户有责任承担额外 40% 的整个医疗费用, 保险公司保留不承担保险责任的权利 1. Hospitalization- Pre-Authorization is required for all locations. (Incl. Hospital stay for Maternity / Delivery); 在所有地方的住院治疗都需要事先授权 ( 包括生育 / 分娩的住院 ); 2. Outpatient Surgeries requiring general anesthesia; 任何需要全麻下进行的门诊手术 ; 3. Skilled or Private Duty Nursing - (When 4 or more visits are required); 专业或私人护士家庭护理 ( 当需要 4 次或 4 次以上时需要事先授权 ); 4. Organ, Bone Marrow, Stem Cell Transplants, and other similar procedures; 器官 骨髓 干细胞或其他组织移植 ; 5. Air Ambulance - Air Ambulance service will be coordinated by Insurer s air ambulance provider; 空中紧急转运 空中紧急转运服务将由保险公司指定转运供应商协调 ; 6. Any condition, including cancer treatment or any chronic condition, which does not meet the above criteria, but are expected to accumulate over 60,000 of medical treatment per policy year; 任何治疗, 包括癌症和慢性疾病的治疗, 虽然不在上述范围之内, 但是一个保险年度内累计预计花费超过人民币 60,000 元, 需要事先授权 ; 7. Hospices; 临终关怀 ; 8. Pre-Authorization through GBG Assist is required if you have a medication that will be in excess of $ 3,000 / CNY18,000 per refill; 如果您的单次配药金额预计超过 3,000 美元或人民币 18,000 元, 请联系 GBG 援助中心以获得事先授权 ; 9. Other conditions and treatment required pre-authorization in the proposal or policy. 其他条款及计划书中约定需事先授权的项目及治疗 In cases of emergency when pre-authorization is not possible, the member should seek care as quickly as possible in the nearest appropriate facility. GBG Assist and the GBG China must be notified within 48 hours of the occurrence in order to avoid the 40% co-pay for non-notification. 如果紧急情况不允许获得事先授权, 您必须在急诊 48 小时内通知国际医疗网络及中国服务中心, 确保不必因没有事先通知而要自负 40% 的费用 13

14 Appendix I 附页一 Enrollment Guidelines 入保指导 1. Children aged 0 17 can only be enrolled as dependent children of the primary insured; 0 17 周岁子女只能以附属被保险人身份入保 ; 2. You are eligible for coverage if you have not attained age 65 at the time of enrollment. You may renew your policy through age 71; 最高入保年龄为 64 周岁, 续保时最高年龄为 71 周岁 ; 3. Children are eligible up to age 25 at the time of enrollment who depend on the primary insured for sole support and who live with the employee in a customary parent-child relationship; 主被保险人的配偶或子女 ( 最高入保年龄为 25 周岁且无独立经济能力 ) 可作为本合同的附属被保险人 ; 4. The dependents should be enrolled at the same time as the primary insured unless there is a family status change. The chosen benefits should be the same; 如有附属被保险人, 须与主被保险人同时入保并且选择同种保障, 家庭情况变更时例外 ; 5. Optional Maternity benefit is only available for married couples enrolling at the same time; 可选生育福利只适用于家庭中夫妻双方同时入保的情况 ; 6. The entire family shall choose the same coverage and benefits at the time of policy effective date or the renewal date, including self-pay; 所有家庭成员必须同一时间选择相同福利套餐投保及续保, 包括自付额 ; 7. The child born from a non-covered pregnancy is subject to underwriting approval; 非保单承担保险责任的生育项下出生的婴儿如需要加入保险计划, 需保险公司核保审核 ; 8. None of insureds are currently suffering from a catastrophic illness Definition on Note 1; 被保险人中必须无人罹患重大疾病 定义见备注一 ; 9. Lump-sum annual payment is required. 本保单仅接受年缴保费方式 Note 1: Catastrophic Illness 备注一 : 重大疾病 1. Cancer: The presence of uncontrolled growth and spread of malignant cells and invasion of tissue. Incontrovertible evidence of such invasion of tissue or definite histology of a malignant growth must be produced. The term Cancer also includes leukemia, lymphomas and Hodgkin s disease. Non-invasive carcinomas in situ localized non-invasive tumors showing only early malignant changes, tumors in the presence of any human immune-deficiency virus and all skin Cancers except malignant melanomas are excluded from the definition of Catastrophic Illness. 癌症 : 指存在恶性细胞失控增长和蔓延并浸润组织现象 有此类浸润组织的详细证据或明确的组织学恶性增长情况 术语 癌症 也包括白血病 淋巴瘤和霍奇金病 以下情况都排除在重大疾病的定义之外 : 只表现出早期恶性变化的位于非浸润性肿瘤中的非浸润性原位癌 ; 在感染获得人体免疫缺陷病毒之后的肿瘤 ; 除了恶性黑色素瘤以外的一切皮肤癌症 2. Major Organ Failure and/or Transplant: The process, as a recipient, of a transplant of any major organ and the medical treatment preceding and following the approved transplant. 重大器官衰竭和 / 或移植 : 指患者作为器官接受者, 进行的任何重大器官移植 药物治疗以及术后措施 14

15 Appendix II 附页二 3. Heart Attack: Death of a portion of heart muscle as a result of abrupt interruption of adequate blood supplies to the diagnosis will be based upon all of the following criteria: a history of typical chest pain new electrocardiograph changes an elevation in cardiac enzyme levels. 心脏病发作 : 由于突然中断的足量血液供给导致的部分心肌死亡, 此诊断必须基于以下所有条件 : 典型胸痛的心电图变化, 心肌酶谱的上升 4. Stroke: Any cerebrovascular incident producing neurological sequelae lasting more than 24 hours and including infarction of brain tissue, hemorrhage or immobilization from an extra cranial source. Evidence of permanent neurological deficit must be produced. The catastrophic illness must be diagnosed by a registered medical practitioner and must be supported by clinical, radiological, histological, and laboratory evidence acceptable to the insurer. 中风 : 任何脑血管意外造成的持续超过 24 小时的神经性后遗症, 包括脑组织血块形成, 额外的颅内出血或出血凝固 永久性神经功能缺损必须有相关依据, 此重大疾病的诊断必须由保险公司认可的注册医生结合临床, 放射, 组织学的证据来做出 5. Coronary Artery Diseases and Peripheral Vascular Disease: Coronary Artery Disease is defined as a disease of the arteries that supply blood to the heart muscle, causing damage to or malfunction of the heart. Peripheral Vascular Disease is defined as narrowing of blood vessels in the legs, and sometimes in the arms, restricting blood flow and causing pain and other medical complications in the affected area. 冠状动脉疾病和周围血管疾病 : 冠状动脉疾病是一种供应心肌血液的动脉疾病, 会引起心脏损伤或功能不全 周围血管疾病是一种腿部小血管疾病, 有时也发生在手臂, 会限制受影响部位的血流, 导致疼痛和其他并发症 Note 2: Provider Co-payment: 100% 备注二 : 通常惯例自付比例 : 100% No coverage in the providers listed below. This also applies to other similarly priced medical facilities. 保险公司对以下医院或与其类似收费标准的医疗机构所产生的费用均不予赔付 1. Guangzhou CanAm International Medical Center 广州加美医疗中心 2. ParkwayHealth Clinics / Gleneagles Medical and Surgical Center 百汇医疗 / 上海百汇华鹰门诊部 3. Institute for Western Surgery 国际外科手术中心 4. International SOS Clinics 国际 SOS 诊所 5. Klinoerth Therapy Clinic 明珍健康信息咨询综合医院 6. Shanghai East International Medical Center 上海东方联合医院 / 上海东方国际医院有限公司 7. SinoUnited Health 盛和康复医疗中心 8. United Family Hospitals and Clinics 和睦家医院 9. Shanghai Redleaf Women's Hospital 上海红枫亚泰妇产医院 10. International Division of Huashan Hospital Pudong, Fudan University (Shanghai International Hospital) 复旦大学附属华山医院东院国际部 ( 上海国际医院 ) 11. Asia Medical Specialists / Sports physicians (Sports performance) Ltd. (Hong Kong) 亚洲专科医生 / 运动内科医生有限公司 ( 香港 ) 12. Hong Kong Adventist Hospital (Hong Kong) 港安医院 ( 香港 ) 13. Hong Kong Sanatorium & Hospital (Hong Kong) 养和医院 ( 香港 ) 14. Matilda International Hospital (Hong Kong) 明德国际医院 ( 香港 ) 15. Other new similarly-priced facilities 其他新的类似收费标准的医疗机构 15

16 Appendix III 附页三 Note 3: Pre-existing and Waiting Period 备注三 : 既往症和等待期 Pre-existing Conditions: Any Illness or Injury, physical or mental condition, for which an Insured Person received any diagnosis, medical advice or treatment, or had taken any prescribed drug, or where distinct symptoms were evident prior to the effective date. Eligible applicants will submit a Health Statement for coverage consideration. Coverage is not guaranteed and subject to underwriting approval. A 24-month waiting period for pre-existing conditions will apply as stated below. After a period of 24 months continuous insurance under the plan, approved pre-existing medical conditions will be covered. Additional exclusions may also apply. Non-disclosed conditions are not covered. 既往症 : 在保险人对其保险责任生效前被保险人已就此接受诊断 医学咨询或治疗, 或服用药物, 或显现症状的任何疾病或损伤或精神疾病 符合入保条件的申请人都需填写健康问卷以供保险公司进行核保 针对既往症将适用 24 个月等待期 经保险公司核保通过的既往症在被保险人加入保险计划连续 24 个月后纳入保险责任范围 其他责任免除也同时适用 对在健康问卷中被保险人未列明的既往症, 保险公司不承担保险责任 Note 4: General Exclusions / Limitations 备注四 : 主要责任除外 1. Emergency Dental & Routine Dental Benefits 紧急牙科以及常规牙科福利 2. Hotel Fees (for an accompanying person in case of emergency medical evacuation) 酒店费用 ( 紧急医疗转运发生时陪同人员住宿 ) 3. Repatriation of Mortal Remains / Local Burial 遗体遣返和就地安葬 4. Congenital Condition 先天性疾病 5. Injuries resulting from the abuse of drugs or alcohol consumption and rehabilitation treatment for alcohol and drug Abuse 酒精和药物滥用引起的伤害以及在门诊和住院戒断治疗费 6. Outpatient Hospice Care 门诊临终关怀 7. Outpatient Therapeutic Services including but Not limited to Physical Therapy, Chiropractic, Occupational Therapy, Vocational Speech Therapy 门诊理疗费, 包括但不限于物理治疗 脊柱指压治疗 职业性治疗及语言障碍治疗 8. Non-Emergency Use of Emergency Room 非紧急情况下的使用急诊室的费用 9. Home nursing 家庭护理费 10. Ground Ambulance and Emergency Medical Evacuation not resulting an inpatient hospitalization 救护车或紧急医疗转运且未在转运后即刻接受住院治疗 11. Injuries resulting from War and Terrorism 战争及恐怖主义导致的伤害 12. All vitamins, minerals, and dietary supplements prescribed or purchased over the counter, except during pregnancy 维生素, 矿物质, 营养品等 ( 不包括妊娠期内医师处方开具的维生素和钙剂费或治疗 ) 13. Cosmetic surgery, Obesity, Self-inflicted injuries 美容手术, 肥胖治疗, 自残引起的伤害 14. Injuries resulting from engaging in professional sports, or activities related to the use of a weapon or firearm (e.g. hunting) 参加或受训职业体育运动引起的伤害 16

17 Appendix IV 附页四 15. Any experimental treatment 不符合医学界普遍认可的并用于实践的治疗方法 手段 设备 药品等实验性医疗费 16. Any reproductive treatments, including abortion, contraception, infertility, sterilization, sexual dysfunction, and post/pre-natal classes 与计划生育相关的治疗 节育 不孕不育 非紧急情况下流产或性功能障碍及优生优育培训咨询费用 17. Treatment to change the refraction of one or both eyes (laser eye correction) 视觉治疗相关费用, 激光角膜切开术 准分 子激光原位角膜磨镶术, 屈光不正 ( 包括近视 远视 ) 校正手术费 18. Sex change operations and related treatments 变性手术及变性相关治疗 19. AIDS / HIV no matter whether pre-existing or not 艾滋病 / 获得性免疫缺乏综合症 ( 无论是否为既往症 ) 20. Charges in excess of usual and customary charges 超过通常惯例部分的医疗费用 21. Annual Full Body checkup, routine exams, immunizations 全身体检 ; 常规检验和免疫接种 Note 5: Currency Exchange 备注五 : 货币换算 1. When services are utilized in the USA, the benefits will be managed in USD, and claims are reimbursed in USD; 当任何服务发生在美国时, 一切福利通过美金办理, 所有的理赔将用美金支付 ; 2. When services are utilized in China, the benefits will be managed in CNY, and claims are reimbursed in CNY; 当任何服务发生在中国时, 一切福利通过人民币办理, 所有理赔将用人民币支付 ; 3. When services are utilized outside the USA and China, the benefits will be managed in CNY, and at the time of claim payment, the reimbursement amount will be converted to CNY based upon the rate of exchange (Using Oanda published exchange rates) in effect at the time the services were rendered; 当服务发生在美国与中国以外的任何其他区域, 一切福利通过人民币办理, 理赔发生时, 相关数额将根据服务发生日汇率 ( 采用 Oanda 发布汇率 ) 以通过人民币赔付 ; 4. All limits and monetary amounts shown herein shall in all instances be in CNY (or USD equivalent converted at exchange rate: USD/CNY 6.25). 在本计划书中, 所有赔偿限额 / 保险金额均以人民币或按美元兑人民币汇率为 6.25 换算的等值美元计算 Note 6: Policy Renew 备注六 : 续保 About the Policy Renewal: The insured shall fill out the application to confirm the renewal as well as pay the renewal premium no later than the 20 days after the policy expiration date. 关于续保 : 本合同的被保险人须在不晚于该保单载明的结束日期起 20 天内填写完整投保单确认续保并足额支付续保保险费 17

18 Appendix V 附页五 I have been informed of the terms and conditions of the insurance plan. I accept these terms and conditions. 如您已充分了解您所申请的保险计划内容并确认无误, 请在此处亲笔签名确认 若有任何疑问, 请联系您的销售人员 Applicant Signature 申请人 ( 投保人 ) 亲笔签名 Date Signed 亲笔签署日期 F