华泰财产保险股份有限公司

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乳规糜
7 years ago
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1 附加个人旅行医疗费用补偿保险条款请仔细阅读保险条款全文, 特别是以粗体标注的免除保险人责任的规定附加保险条款订立第一条本附加保险条款 ( 以下简称本附加条款 ) 须附加于主保险合同 ( 以下简称主合同 ) 第二条主合同的被保险人均可作为本附加条款的被保险人投保本附加险保险责任第三条一在本附加条款的保险期间内, 被保险人持有有效证件在境内或境外旅行期间, 遭受意外伤害事故, 且自意外伤害事故或突发性疾病 ( 见释义第 1 条 ) 发生之日起五日内到医院或保险人认可的医疗机构进行治疗的, 保险人以本附加条款的保险金额为限, 在下列情形中负责赔偿超过免赔额部分的费用 : 1 如意外伤害事故或罹患突发性疾病发生在境外的, 自意外伤害事故或罹患突发性疾病发生之日起九十日内, 被保险人在事故发生地所在国家或地区的医院进行治疗所发生的, 符合本附加条款的, 实际支出的合理惯常必需且经保险人认可的医疗费用, 包括医生诊断费处方费手术费住院费药费 ( 仅限于医生处方所指定的药品 ) X 光检查医疗用品救护车等费用 2 如意外伤害事故发生在境内的, 自意外伤害事故发生之日起九十日内, 被保险人在境内医院进行治疗所发生的, 符合本附加条款的, 实际支出的合理惯常且必需的符合当地社会医疗保险主管部门规定的医疗费用保险人对境内治疗地基本医疗保险支付范围之外的药品检查治疗材料等费用不负赔偿责任 3 如意外伤害事故或罹患突发性疾病发生在境外的, 被保险人回国后在境内继续治疗所发生的以下医疗费用, 以保险单或保险凭证中所载保险金额的 20% 为限 : (1) 被保险人返回境内后需要继续治疗的, 被保险人返回境内后三十日内 ( 但最长不超过意外伤害事故或罹患突发性疾病发生之日起九十日 ) 发生的医疗费用 ; (2) 在境内医院进行治疗所发生的, 符合本附加条款的, 实际支出的合理惯常且必需的符合当地社会医疗保险主管部门规定的医疗费用 4 本附加条款承担的牙科治疗费用仅限于因遭受意外伤害事故导致的牙齿伤害, 在医院或保险人认可的医疗机构经医生诊断, 必须进行的为减轻剧痛而支付的合理紧急牙科治疗费用, 包括医生诊断费手术费药费 ( 仅限医生处方中用于减轻疼痛的药品 ) 二可选保险责任投保人可以增加额外保险责任, 由保险人和投保人在投保单另行约定保险人将根据该约定对被保险人在下述情形下或期间内遭受的保险事故, 按照约定负责赔偿 : 1 流行疫病或大规模流行疫病责任免除第四条对被保险人发生的下列医药费用支出, 保险人不承担赔偿责任 : ( 一 ) 被保险人康复性治疗物理治疗安胎及分娩 ( 包括剖腹产流产及引产 ) 等

2 所产生的费用 ; ( 二 ) 因慢性病或旅行前已罹患疾病的治疗 ; ( 三 ) 因流行疫病或大规模流行疫病导致的治疗或预防发生的医疗 ; ( 四 ) 因脊椎间盘突出症或错位的治疗 ; ( 五 ) 因避孕或绝育手术发生的治疗 ; ( 六 ) 因药物过敏发生的治疗 ; ( 七 ) 因扁桃腺腺样体疝气女性生殖器官疾病的治疗或上述疾病导致的手术产生的治疗 ; ( 八 ) 此次旅行之前已被有资质的职业医师诊断为身患绝症 ; ( 九 ) 被保险人护理 ( 陪住 ) 费取暖费伙食费误工费及装配假眼假牙假肢用于矫形整容安装残疾用具聘用特别看护或私家看护等需要自付的费用 ; ( 十 ) 被保险人美容整形矫形术非必须紧急性治疗的手术心理咨询及角膜屈光成形手术所产生的费用 ; ( 十一 ) 被保险人健康护理 ( 含体检健康体检疗养特别护理或静养 ) 等非治疗性的行为及无客观病征证明其不健康及以捐献身体器官为目的的医疗行为所产生的费用 ; ( 十二 ) 被保险人移植人工器官验光洗牙洁齿牙齿治疗或手术及镶补所产生的费用, 但因意外伤害引起的一般牙齿治疗或手术除外 ; ( 十三 ) 被保险人先天性疾病 ( 见释义第 2 条 ) 和症状遗传性疾病先天性畸形或缺陷的治疗和康复所产生的费用 ; ( 十四 ) 被保险人投保前已患上的疾病和症状精神病精神分裂症心理疾病性病的治疗和康复所产生的费用 ; ( 十五 ) 根据被保险人的主治医生或救援机构的意见, 可以被合理延迟至被保险人返回其原出发地 ( 见释义第 3 条 ) 后进行, 而被保险人坚持在当地进行治疗或手术所产生的费用 ; ( 十六 ) 到达医院前, 任何因当地急救组织或第三方提供服务而被保险人不需负责给付的费用或任何已包含在旅行收费中的费用 ; ( 十七 ) 到达医院前, 任何被保险人未经保险人同意擅自使用或自助选择救助服务所发生的费用 ; ( 十八 ) 无当地医院出具原始发票或收据及医疗证明的费用 ; ( 十九 ) 被保险人在境外遭受意外伤害事故或罹患突发性疾病, 但未在当地经过医生诊断, 而在回原出发地后进行的任何门急诊及住院治疗所发生的费用 ; ( 二十 ) 被保险人在境外遭受意外伤害事故或罹患突发性疾病, 经过当地医生诊断, 但在回原出发地后进行的与本次意外伤害事故或突发性疾病没有直接关系的门急诊及住院治疗所发生的费用 ; ( 二十一 ) 中国境内治疗地基本医疗保险支付范围之外的药品检查治疗材料等费用 ; ( 二十二 ) 主合同所列的各项责任免除事项医疗押金救援服务第五条当被保险人遭受意外伤害事故或罹患突发性疾病时, 如被保险人或其旅行同伴立即通知保险人委托的救援机构或其授权代表 ( 以下简称救援机构 ) 提供医疗服务咨询或安排

3 住院, 对于担保住院期间发生的医疗押金, 在保险人授权的条件下, 救援机构在保险金额内负责为被保险人住院期间医疗费用进行担保保险金额和保险费第六条保险金额是保险人承担给付保险金责任的最高限额保险金额由投保人保险人双方约定, 并在保险单中载明投保人应该按照本附加条款约定向保险人交纳保险费保险人和投保人可以在本附加条款项下约定免赔额及赔付比例等限制条件当被保险人通过救援机构在保险金额内支付医疗费用时, 该费用由保险人直接支付给救援机构, 保险人不接受任何非通过救援机构的索赔若实际医疗费用超过本附加条款的保险金额, 则超出部分的费用由被保险人或其亲属自行与救援机构结算保险期间第七条除非另有约定, 本附加条款的保险期间同主合同一致保险金申请第八条一由被保险人作为索赔申请人填写索赔申请书, 并提供下列证明文件资料向保险人申请索赔 : 1 被保险人户籍证明或身份证明 ; 2 医院出具的附有病理检查代验检查及其他医疗仪器检查报告的医疗诊断证明病历及医疗医药费原始单据出院小结原件 ; 3 保险人认可的意外事故证明文件 ; 4 其他与确认保险事故的性质原因损失程度等有关的证明和资料二以上资料和证明是保险索赔的重要依据, 如索赔申请人未能及时提供有关单证, 导致保险人无法核实单证的真实性及其记载的内容的, 保险人对无法核实部分不负赔偿责任三所有本附加条款的损失计算和保险金支付在涉及外国货币时, 均折合人民币计算, 并以人民币赔偿有关汇率以保险事故发生日的中国银行挂牌外汇中间价为准四若被保险人的损失可从其他途径或其他保险公司获得赔偿的, 被保险人应当首先向有关当事方请求赔偿保险人可根据有关单位或保险公司出具的相关单证或给付保险金证明, 在按照本附加条款赔偿保险金时, 相应扣减被保险人已从其他途径或其他保险公司获得的赔偿金五当赔付金额未达实际支出住院医疗费用的金额时, 索赔申请人可以书面形式向保险人申请发还原始单据, 保险人在加盖印章并注明已赔付金额后发还原始单据第九条本附加条款效力终止以下任何一种情况发生时, 本附加条款效力终止, 保险人不再承担给付保险金的责任 :

4 1 投保人解除本附加条款; 2 主合同解除终止效力或期满; 3 本附加条款因其他条款或保险合同所列情况而终止; 4 主合同无效, 本附加条款亦自始无效释义第十条 1 突发性疾病 : 指被保险人在本附加条款规定的保险期间内, 在旅行时首次罹患的突发性疾病或出现的症状, 但不包括本保险合同生效前罹患的任何疾病或出现的任何症状及任何慢性疾病 2 先天性疾病 : 指人一出生就具有的疾病 ( 症状或体征 ) 这些疾病是因人的遗传物质 ( 包括染色体以及位于其中的基因 ) 发生了对人体有害的改变而引起的, 或因母亲怀孕期间受到内外环境中某些物理化学和生物等因素的作用, 使胎儿局部体细胞发育异常, 导致婴儿出生时有关器官系统在结构或功能上呈现异常 3 原出发地: 若被保险人进行的旅行目的地为中国境内, 则原出发地指被保险人在中国境内的日常居住地 ; 若被保险人进行的旅行目的地为中国境外, 则原出发地指中国境内本附加条款的未解释名词, 均以主合同的名词解释为准其他第十一条本附加条款与主合同主险条款不一致之处, 以本附加条款为准 ; 本附加条款未尽之处, 以主合同主险条款为准

5 MEDICAL EXPENSES REIMBURSEMENT RIDER PLEASE READ THE ENTIRE WORDING CAREFULLY, ESPECIALLY THE HIGHLIGHTED PARTS WHICH EXEMPT THE INSURER FROM LIABILITY UNDER THIS POLICY. CONCLUSION OF RIDER CLAUSES ARTICLE 1 Clauses of this Insurance Rider (hereinafter cited as the Rider Clauses ) shall be applied in conjunction with the main policy (hereinafter cited as the Main Insurance ) specified in the insurance contract to supplement the cover provided. ARTICLE 2 All the Insureds covered under the Main Insurance can be covered under these Rider Clauses. POLICY BENEFITS ARTICLE During the insurance period of the Rider Clauses, if the Insured travels within or outside of China (including Hong Kong SAR, Macau SAR and Taiwan) with the valid travel documents and approaches the Hospital or medical organization approved by the Insurer for medical treatment within five days upon occurrence of an Accident or Sudden Disease (refer to Article 10.1), the Insurer shall be liable to pay, within the limit of relevant insured amount under the Rider Clauses, for the portion above the deductible: Where the Accident or Sudden Disease takes place outside the territory of China, the reasonable, normal and necessary medical expenses in compliance with the Rider Clauses and acceptable to the Insurer, including such expenses as for diagnosis, prescription, surgery, hospitalization, medicine (designated in the prescription of the doctor), X-ray check, medical articles, ambulance, etc, which have been actually incurred and paid by the Insured for treatments in the Hospital located in the country or region where the accident takes place within ninety (90) days upon occurrence of such Accident Where the Accident takes place within China, the reasonable, normal and necessary medical expenses in compliance with the Rider Clauses and within the scope of medical expenses as provided by the local administration department for social medical insurance, which have been actually incurred and paid by the Insured in the domestic Hospital within ninety (90) days upon occurrence of such Accident. The Insurer will not be liable to pay the expenses for drug, checkup, treatment and materials beyond the scope of the basic medical insurance applicable at the place of medical treatment within the territory of China Where the Accident or Sudden Disease takes place outside the territory of China and the treatment continues after the Insured returns to China, the following medical expenses incurred by the Insured in China, subject to 20% of the insured amount specified in the policy schedule or

6 certificate: Medical expenses incurred within thirty days after the Insured returns to China (not later than ninety days from the occurrence of the Accident or Sudden Disease), provided it is necessary for the Insured to continue with the treatment after returning to China; Reasonable, normal and necessary medical expenses in compliance with the Rider Clauses and within the scope of medical expenses as provided by the local administration for social medical insurance which are actually paid for medical treatment at domestic Hospitals The reasonable expenses paid for emergent and necessary dental treatment (only for dental injury caused by an Accident) to reduce the sharp pain, as per diagnosis of the professional physician in the Hospital or in the medical organization acceptable to the Insurer, including the expense of diagnosis, surgery and cost of drugs in prescription used to kill pain; 3.2 Optional Benefit The Policyholder may elect the additional benefit listed below, which will be specified in the Policy Schedule with the agreement of the Policyholder and the Insurer. The Insurer will liable to pay for the loss in accordance with the agreement, if the insured suffers any insured accident during the insurance period under the following condition: 1. Epidemic and Large-scale Pandemic EXCLUSIONS ARTICLE 4 The Insurer shall not be liable for any medical expenses incurred by the Insured directly or indirectly due to any one of the following circumstances: 4.1 Expenses for recovery treatment, physiotherapy, miscarriage prevention and delivery (including caesarean section, abortion and induced labor) of the Insured; 4.2 Treatment expenses for any chronic disease, or disease suffered prior to the trip; 4.3 Medical expenses for treatment or prevention due to pestilence or pandemic; 4.4 Treatment expenses for intercentrum protrusion or malposition; 4.5 Expenses for contraception or operations related to sterilization; 4.6 Medical expenses due to drug allergy; 4.7 Treatment or surgery for tonsils, adenoids, hernia or a disease peculiar to the female reproductive organs; 4.8 Incurable disease as diagnosed by the qualified physician prior to the trip; 4.9. Such expenses which should be borne by the Insured as nursing (companion) fee, heating, food, idle time, and fitting of artificial eye, false teeth, artificial limb, articles for orthopedic, shaping and disabled, special nursing or private nursing; 4.10 Cosmetology, shaping, orthopaedy, unnecessary surgery, psychological consultation and comeal refractive surgery of the Insured; 4.11 Health care (including physical exam, health exam, recuperation, special nursing care or rest cure) and other non-therapeutic behavior of the Insured and medical behavior

7 without any objective syndrome to prove he/she is unhealthy and for the purpose of donating organs; 4.12 Behavior of the Insured for transplanting artificial organ, tooth wash, tooth cleaning, optometry, dental treatment or surgery and insertion, except for the general dental treatment or surgery due to any accident; 4.13 Treatment and recovery for Congenital Disease (refer to Article 10.2) and symptom, hereditary disease, congenital malformation or defect of the Insured; 4.14 Disease and symptom, psychosis, schizophrenia, psychological disease and STD the Insured has suffered before the insurance is purchased; 4.15 Local medical treatment or surgery the Insured insists to take, though such medical treatment or surgery can be reasonably postponed or undertaken when the Insured returns to Original Departing Place (refer to Article 10.3) as advised by the doctor who is in charge of the Insured or authorized doctor of the assistance organization; 4.16 Any expense for local rescue organization or a third party to provide services which the Insured is not required to pay for, or any expense included in the travel expenses, before arrival at the Hospital; 4.17 Any expenses for the assistance service used or selected by the Insured without the consent from the Insurer before arrival at the Hospital; 4.18 Expenses without any original or medical certificate issued by the local Hospital; 4.19 Where the injury accident or Sudden Disease takes place outside the territory of China, expenses for any clinic or emergency treatment and hospitalized treatment undertaken by the Insured upon returning to Original Departing Place for the initial medical treatment due to the insurance liability hereto, which has not been diagnosed by local professional physician; 4.20 Expenses for any clinic or emergency treatment and hospitalized treatment undertaken by the Insured though the initial medical treatment due to the insurance liability covered by the Rider has been diagnosed by the professional physician abroad, but such follow-up treatment taken upon returning Original Departing Place is not directly associated with the accidental injury or Sudden Disease incurred abroad, which is covered by the Rider; 4.21 The drug, checkup, treatment and materials beyond the scope of payment under the basic medical insurance at the place of medical treatment within the territory of China Items specified in the exclusion clause of the Main Insurance. MEDICAL DEPOSIT AND ASSISTANCE SERVICE ARTICLE 5 When the Insured suffers any Accident or Sudden Disease and the Insured or his/her traveling companion immediate notifies the assistance organization entrusted by the Insurer or its authorized agent (hereinafter cited as Assistance Organization ) to provide medical treatment service consultancy or arrange for hospitalization, the Assistance Organization will provide the guarantee, within the limit of the insured amount, for the medical expenses to be incurred during hospitalization of the Insured, subject to the authorization of the Insurer.

8 INSURED AMOUNT AND PREMIUM ARTICLE 6 The insured amount refers to the maximum amount for compensation or insurance money payment to be paid by the insurer. The insured amount is to be agreed upon by the Policyholder and the Insurer and shall be expressly indicated in the policy schedule. The Policyholder shall pay the insurance premium to the Insurer according to this Contract. The Insurer could stipulate the deductible with the Policyholder under the clause of this Contract. Where the Insurer pays for the medical expenses under the insurance amount through the assistance institution, the expenses shall be paid directly to the assistance institution by the Insurer. The claim will not be accepted except it s from the assistance institution. Where the actual medical expenses exceed the insurance amount under this Rider clause, the extra expense will be settled directly between the Insured or his/her relatives and the assistance institution. INSURANCE PERIOD ARTICLE 7 Unless otherwise agreed, the insurance period of the Rider Clauses shall be the same with the Main Insurance Contract. APPLICATION FOR INSURANCE BENEFIT ARTICLE As the Claimant, the Insured shall fill up the claim application and provide the following documents and materials to apply to the Insurer for the claim payment: Household registration or ID certificate of the Insured; Medical diagnosis certificate, medical record and original bills of medical treatment and medicine and original dispatch note issued by the Hospital, with attachment of such reports as pathological examination, consigned examination and other medical examination with medical instrument; Certification document of accident acceptable to the Insurer; Other certification and documents in connection with verification of the nature, reason and loss of the insurance accident. 8.2 The above documents and certification are the important evidence for insurance claim. Where the Insurer fails to verify the truth of evidence and content thereof due to the failure of the claim applicant to provide such evidence timely, the Insurer shall not be liable to compensate for the portion that cannot be verified. 8.3 In case of any foreign currency involved in calculating the loss and paying the insurance benefit under the Rider Clauses, it shall be converted into and paid in RMB. The relevant exchange rate shall be subject to the foreign exchange rate published by Bank of China on the date

9 when the insurance accident under the Rider Clauses happens. 8.4 Where such loss of the Insured can be compensated by other approaches or other insurance policies, the Insured should first request the opposite party for payment or compensation. According to the relevant evidence or benefit payment certificate issued by the relevant institution or insurance underwriting company, the Insurer may undertake the liability to compensate, within the limit of insured amount under the Rider Clauses, for the remaining portion other than the above compensation amount to the Insured. 8.5 When the amount of insurance indemnity is less than the amount actually paid for the hospitalized treatment expenses, the Claimant may request in writing the Insurer for return of the original bills and the Insurer will return the original bills stamped with the seal and marked with the amount of insurance indemnity paid. ARTICLE 9 TERMINATION OF RIDER CLAUSES The Rider Clauses shall terminate automatically under any of the following circumstances and the Insurer shall no longer be liable to pay the benefits: 9.1 The Policyholder terminates the Rider Clauses; 9.2 The cancellation, termination, or expiry of the Main Insurance; 9.3 The Rider Clauses shall terminate under other terms and conditions or due to any circumstances stated in the Contract; 9.4 The Rider Clauses shall be null and void if the Main Insurance is deemed null and void. ARTICLE 10 DEFINITIONS 10.1 Sudden Disease means any sudden disease suffered or symptom observed initially by the Insured travelling within the validation of the Rider Clauses, but excluding any diseases suffered or any symptom observed prior to the validation of the Rider Clauses and any chronic disease Congenital Disease means the disease (signs or symptoms) which is present at the birth of a person. These diseases are caused by changes of the human genetic material (including the chromosome and its gene) which are harmful to the human body; or caused by the certain physical, chemical and biological factors from internal or external environment during pregnancy; as a consequence partial somatic cells developed abnormally causing architecture or function abnormality of organ system at birth Original Departing Place means that if the Insured travels within the territory of China, then the original departing place is the residence of the Insured within the territory of China; If the Insured travels Outside of China, then the Original Departing Place means within the territory of China. Any term not interpreted in the Rider Clauses shall be subject to the interpretation of the term in the Main Insurance to which the Rider Clauses is attached.

10 MISCELLANEOUS ARTICLE 11 Where the Rider Clauses conflict with the terms of the Main Insurance, the Rider Clauses shall prevail; where it is not specified in the Rider Clauses, the terms of the Main Insurance shall prevail.

华泰财产保险股份有限公司

华泰财产保险股份有限公司华泰财产保险有限公司附加旅行医疗费用保险条款使用第一条附加保险合同订立本附加保险条款 ( 以下简称本附加条款 ) 须附加于保险合同列明的保险人主险条款第二条保险责任一在保险期间内, 被保险人持有有效证件在境内或境外旅行期间, 遭受意外伤害事故或罹患突发性疾病 ( 见第 1 条释义 ), 且自意外事故或突发性疾病发生之日起五日内到医院 ( 见第 2 条释义 ) 进行治疗的, 保险人按照本保险合同约定负责赔偿