Ping An Accidental Injury Group Medical Treatment Rider

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					           Ping An Accidental Injury Group Medical Treatment Rider
                                       (PingBaoYangFa[2009] No. 105,
          submitted to the China Insurance Regulatory Commission for the record in September 2009)


     Note:
     The boldfaced contents are the clauses exempting the Company from liabilities, please read carefully.

     Article 1 Composition of Insurance Rider
     This Rider (hereinafter referred to as “the Rider”) is composed of insurance policy or other insurance certificate
and attached clauses, insurance application form, name list of insurants and other application documents relevant to the
Rider, legal and valid statements, endorsements, memoranda and other written agreements.
     Article 2 Formation and Effectiveness of Insurance Rider
     The Rider shall be formed when the applicant makes an insurance application and the Company agrees to provide
the insurance.
    The Rider shall become effective as of the date when the Company agrees to provide the insurance, charges the
premium and issues the insurance policy. The effective date shall be subject to the date as indicated in the policy.
     Article 3 Eligibility
     A group may, as the applicant, apply to the Company for this insurance for its members. The spouses and children
of participating members may also participate in this insurance, unless otherwise specified.
     Article 4 Insurance Liabilities
     During the effective period of the Rider, the Company will assume the following insurance liabilities:
     If the insured suffers from an accident and is hospitalized for medical treatment, the Company will pay accidental
medical benefits at the agreed payment proportion of the reasonable medical expenses occurring within 180 days after
occurrence of this accident and conforming to the local regulations concerning basic social medical insurance after
deducting the agreed deductible.
     If the insured suffers from one accident or several accidents and incurs reasonable medical expenses, the
Company will pay accidental medical benefits respectively according to the above provisions, but the aggregate of the
benefits paid sums up to the sum insured for the medical treatment of the insured’s accidental injury. When the
aggregate of the benefits paid sums up to the sum insured for the medical treatment of the insured’s accidental injury,
the insurance liability for the insured will terminate.
     The Company will pay insurance benefits within the coverage of the Rider. But if the insured has been
reimbursed from other channels (including, but not limited to, social medical insurance institution, working
unit, any commercial insurance institution including the Company, etc), the Company will only assume the
insurance liability for the remaining reasonable medical expenses conforming to the payment scope of local
social medical insurance within the sum insured.
    If the insured receives medical treatment abroad, the reasonable medical expenses within the coverage of the
Rider will be determined according to the average level of domestic same treatment.
     Article 5 Exclusions
     The Company will not reimburse any insurance benefits if the insured incurs medical expenses due to any
of the following circumstances:
     (1) The applicant kills or injures the insured intentionally;
     (2) The insured intentionally injures himself/herself, commits a crime or resists any criminal coercive
measure taken according to law;
     (3) The insured fights, drinks excessively, or takes or injects drugs;
     (4) The insured drives under the influence of alcohol or without a valid driving license or the motor vehicle
which does not have a valid driving permit;
     (5) War, military conflict, riot or armed revolt;
     (6)Nuclear explosion, nuclear radiation or nuclear pollution;
     (7)The insured suffers from any injury due to gestation (including ectopic pregnancy), miscarriage and
parturition (including cesarean section);
    (8)Intervertebral disc herniation (including intervertebral bulge, intervertebral protrusion, intervertebral
prolapse, free intervertebral disc, etc);
     (9)The insured is injured due to medical accident, medicine allergy or mental and behavioral disorders (as
determined according to the Tenth Revision of the International Statistical Classification of Diseases and
Related Health Problems (ICD-10) released by the World Health Organization);
   (10)The insured takes any medicines without the permission of his/her doctor, but excluding the use of
OTC medicines according to use instructions;
     (11)Bacterial or virus infection (excluding wound infection due to an accident);
    (12)The insured participates in diving, parachuting, rock climbing, bungee jumping, aerodone or
paraglider driving, expedition, wrestling, martial art competition, stunt performance, horse racing, motor
racing, or any other high-risk sport.
     Article 6 Sum Insured and Premium
     The sum insured and premium under the Rider will be agreed with the Company when the applicant applies for
the insurance and indicated in the insurance policy.
     The applicant shall pay the premium in a lump sum when he or she applies for the insurance.
     Article 7 Insurance period and renewal
     The insurance period of the Rider is 1 year.
     Upon expiry of the insurance period of the Rider, the applicant may apply to the Company for renewal of this
insurance. Upon examination and approval, the Company will handle renewal procedures for the applicant,
re-determine the premium rate depending on the risk nature of the insured at the time of renewal and charge the
premium.
     Article 8 Clear Explanation and Statement of Truth
     When signing the Rider, the Company will explain the contents of the Rider to the applicant. For the clauses of
the Rider exempting the Company from liabilities, when signing the Rider, the Company will give prompts sufficient
to alert the applicant in the insurance application form, insurance policy or other insurance certificate and clearly
explain the contents of these clauses in writing or orally to the applicant. In the event of no prompts or clear
explanation, these clauses shall be of no effect.
     The Company may make inquiries on the information relevant to the applicant and the insured, and the applicant
shall give a true statement on such information.
     If the applicant fails to perform his/her obligation of giving a true statement as specified in the foregoing
paragraph intentionally or due to gross negligence, which may affect the Company’s decision to provide the insurance
or increase the premium rate, the Company is entitled to terminate the Rider or cancel the insurance qualification of
such insured.
     If the applicant intentionally fails to perform his/her obligation of giving a true statement, the Company is neither
required to pay any insurance benefits for the occurrence of any insurance event prior to the termination of the Rider or
the cancellation of the insurance qualification of such insured, nor to refund the paid premiums.
     If the applicant fails to perform his/her obligation of giving a true statement due to gross negligence and such
failure materially affects the occurrence of the insurance event, the Company is not required to pay any insurance
benefits for the occurrence of any event prior to the termination of the Rider or the cancellation of the insurance
qualification of such insured, but has to refund the paid premiums.
     If, when signing the Rider, the Company has known that the applicant did not give a true statement, the Company
shall neither terminate the Rider nor cancel the insurance qualification of such insured. If any insurance event occurs,
the Company shall be obliged to pay the insurance benefits.
     Article 9 Limitation on the Company’s right of termination
     The right to terminate the Rider as specified in the foregoing article shall be ineffective if not exercised beyond
30 days after it knows the cause for termination.
     Article 10 Beneficiary
    The applicant or the insured may designate one person or several persons as the beneficiary (ies) of insurance
benefits. Except as otherwise provided, the beneficiary of accidental medical benefits shall be the insured
himself/herself.
     When there are several beneficiaries, benefiting sequence and shares may be determined. If no shares are
determined, each beneficiary is entitled to beneficial right under equal shares.
     When the applicant applies for personal insurance for the laborer with whom the applicant has labor relationship,
no person other than the insured and his or her near relatives may be designated as the beneficiary.
     If the insured is a person without capacity for civil conduct or with limited capacity for civil conduct, his or her
guardian may designate the beneficiary.
     The applicant or the insured may change the beneficiary and notify the Company in writing. After receiving the
written notification about beneficiary change, the Company will endorse this change in or affix an endorsement to the
insurance policy or other insurance certificate.
     When the applicant designates and changes the beneficiary, he or she shall obtain the consent of the insured.
     In the event of the death of the insured, insurance benefits shall be treated as the insured’s legacy and the
Company shall, in any of the following circumstances, be obligated to pay insurance benefits in accordance with the
Law of Succession of the People’s Republic of China:
     (1) where there is no designated beneficiary or the beneficiary cannot be determined due to unclear designation;
     (2) where the beneficiary dies before the insured without other beneficiary being designated; or
    (3) where the beneficiary forfeits or surrenders his rights as such in accordance with law without any other
beneficiary.
     If the beneficiary and the insured dies from the same event and the sequence of death cannot be determined, it is
presumed that the beneficiary dies before the insured.
     If the beneficiary has intentionally caused the death, disability or disease of the insured, or attempted to cause the
death of the insured, the beneficiary shall forfeit his right to claim insurance benefits.
     Article 11 Notification of insurance event
         The applicant or the beneficiary shall notify the Company of the insurance event within 10 days after being aware
of it.
    If the applicant or the beneficiary fails to give a timely notification intentionally or due to gross negligence
and causes the difficulty in determining the nature and reason of the insurance event, degree of loss, etc, for the
portion that cannot be determined, the Company will bear no liability to pay any insurance benefits, unless the
Company has timely known by other means or should timely know the occurrence of the insurance event, or the failure
to give a timely notification does not affect the Company in determining the nature and reason of the insurance event
and the degree of loss.
         Article 12 Claim for insurance benefits
         The claimant for accidental injury medical benefits fills in the claim form for benefits and provides the following
certificates and materials:
         (1) Insurance contract;
         (2) Claimant’s valid identity certificate;
         (3) Medical records;
         (4) Original voucher of medical expenses and settlement list of medical expenses issued by the hospital;
         (5) Other available certificates and materials relating to the determination of the nature, reason, etc of insurance
event.
     If insurance benefits are used as the insured’s heritage, the relevant right document evidencing lawful right of
inheritance must be provided
         When the claimant claims benefits, if the certificates and materials provided above are incomplete, the Company
will timely notify the claimant at one time of relevant certificates and materials needing to be provided.
      Article 13 Payment of Insurance Benefits
         After receiving the claim form for insurance benefits and the relevant certificates and materials as above, the
Company will verify the claim within 5 days; if the situation is complicated, the Company will verify the claim within
30 days, unless otherwise provided.
         If the claim is covered by insurance liability, the Company will pay insurance benefits within 10 days after
reaching an agreement for payment of insurance benefits with the beneficiary.
     If the Company fails to timely perform the obligation in the foregoing paragraph, in addition to insurance benefits,
the Company will compensate the losses thus incurred by the beneficiary.
    If the claim is not covered by insurance liability, the Company will, within 3 days from verification, give to the
beneficiary a notice about refusing to pay benefits and explain the reason.
         If the Company cannot determine the amount of benefits to be paid within 60 days of receiving the claim form for
insurance benefits and relevant certificate and materials, the amount of benefits that can be determined according to
available certificates and materials will be first paid; after the Company finally determines the amount of benefits, the
difference will be paid.
         Article 14 Limitation of action
         The period of limitation of action for the beneficiary to claim insurance benefits against the Company is 2 years,
counted from the date when he or she knows or should know the occurrence of the insurance event.
         Article 15 Change of the Insured
         (1) If the applicant needs to add participating members due to the change of the group members participating in
this insurance, shall notify the Company in writing. Upon examination, approval and receipt of corresponding
premium, the Company will begin to bear the insurance liability.
     (2) During the effective period of the Rider, if the applicant needs to surrender the insurance because the group
members participating in this insurance no longer serve the applicant or lose the membership, it shall notify the
Company in writing and the Company’s insurance liability for relevant insured (including this member and his or her
spouse and child who are not the participating group members) will terminate as of the date when this member no
longer serves the applicant or loses membership. The Company will refund to the applicant the unearned net premium
corresponding to such insured.
     (3) When the number of the insureds under the Rider is less than 75% of the persons eligible for this insurance,
the Company is entitled to terminate the Rider and refund to the applicant the unearned net premium.
     Article 16 Notification of hazard change
     When the applicant has his or her industry changed or the insured has his or her profession or trade changed, the
applicant shall notify the Company in writing within 10 days.
     If the hazard of the changed industry of the applicant or the changed profession or trade of the insured decreases
according to the Company’s profession classification, as from the date of receiving the notification, the Company will
refund the corresponding unearned net premium according to the difference between the payable premium for changed
hazard and the actually paid premium; if the hazard increases, as from the date of receiving the notification, the
Company will additionally charge the unearned premium according to the difference between the payable premium for
changed hazard and the actually paid premium. If the changed industry of the applicant or the changed profession or
trade of the insured is outside the insurance rejection scope according to the Company’s profession classification, the
Company’s insurance liability for the applicant or the insured will terminate as of the date of receiving the notification
and refund the unearned net premium.
     If the hazard of the changed industry of the applicant or the changed profession or trade of the insured increases
according to the Company’s profession classification, the applicant fails to notify the Company according to the above
provision and an insurance event occurs, the Company will calculate and pay insurance benefits at the ratio of actually
paid premium to payable premium. But the changed industry of the applicant or the changed profession or trade
of the insured is inside the insurance rejection scope of the Company, the Company will bear no liability to pay
insurance benefits.
     Article 17 Age determination and error handling
     (1) The insured’s age is subject to full years of age.
     (2) When the applicant applies for the insurance, he/she shall fill the insured’s date of birth consistent with valid
identity credential in the insurance application form. In case of an error, the following provisions shall apply:
     1. If the insured’s age declared by the applicant is untrue and his/her true age does not conform to the age
limitation as specified herein, the Company is entitled to terminate the Rider or cancel the insurance qualification of
the insured and refund the unearned net premium for the insured to the applicant. The exercise by the Company of the
right of termination shall be subject to the provisions of Article 9 “Limitation on the Company’s right of termination”.
     2. If the insured’s age declared by the applicant is untrue and as a result thereof, the premium paid by the
applicant is less than payable premium, the Company is entitled to make correction and request the applicant to pay the
insufficient portion. If an insurance event has occurred, insurance benefits will be paid at the ratio of paid premium to
payable premium.
     3. If the insured’s age declared by the applicant is untrue and as a result thereof, the premium paid by the
applicant is higher than payable premium, the Company will refund overpaid premium to the applicant.
     Article 18 Address change
     When the applicant’s address changes, he or she shall timely notify the Company in writing. Where the applicant
fails to do so, the Company will give relevant notice to the latest address as indicated in the Rider.
     Article 19 Modification of contract contents
     Within the effective period of the Rider, the applicant and the Company may modify the contents of the Rider
subject to a mutual agreement. Where modifications to the Rider are made, the Company shall endorse them in the
original policy or other insurance certificate or affix an endorsement slip thereto or enter into a written agreement of
modification with the applicant.
     Article 20 Procedures of termination of contract by the applicant
     Where the applicant applies to terminate the Rider, he or she shall fill in the contract termination application and
provide the following to the Company:
     (1) Insurance contract;
     (2) Valid identity credential or identity certificate of the applicant;
    The Rider shall be terminated as of the date when the Company receives the application for contract termination.
Within 30 days of receiving such application, the Company shall refund the unearned net premium under the Rider to
the applicant.
     Article 21 Resolution of dispute
     Any dispute as may arise from or out of the performance of this Rider shall be first resolved by both parties
through negotiations. In the event that no resolution can be reached, such dispute may be referred to arbitration by
signing an arbitration agreement or either party may bring a lawsuit before the competent court in accordance with
law.
     Article 22 Definitions
     [The Company] means Ping An Annuity Co., Ltd.
     [Group] means the legal groups having more than 5 (including 5) members and organized not for insurance
purchase, including organs, enterprises, institutions, social organizations, etc.
     [The insured] means the persons listed in the name list of the insured attached to the Rider.
     [Members] If the groups are organs, enterprises or institutions, members mean the on-the-job employees that are
healthy and can work normally within these groups; if the groups are social organizations, members mean the
members and official staff of these groups.
   [Spouse] means the husband or wife having a legal marital relationship with the insured at the time for applying
for the insurance.
     [Children] means the insured’s children above 30 days of age (who have been discharged out of hospital in a
healthy condition) and unmarried children under 23 full years of age, including children born in wedlock, children
born out of wedlock, legally adopted children and stepchildren with a relationship of bringing-up.
     [Accident] means any objective event of an extraneous, sudden, unintentional and non-disease nature that causes
a bodily injury.
     [Hospital] means the designated hospital as agreed between the Company and the applicant and if no designated
hospital is agreed, means the public hospital above Grade II (inclusive) that conducts lawful operations within the
territory of the People’s Republic of China (excluding Hong Kong, Macao and Taiwan).
     [Medical expenses] means the medical expenses specified by the payment scope of local social basic medical
insurance (excluding self-paid and partially self-paid items and medicines), including bed expenses, operation
expenses, medicine expenses, treatment expenses, care expenses, inspection and examination expenses, special
inspection and treatment expenses and ambulance expenses.
     (1) Bed expenses
     Bed expenses mean expenses for beds used in hospitals (excluding beds in observation wards, companion beds
and family beds).
     (2) Operation expenses
     Operation means those conducted for curing diseases and saving the life of the insured, excluding traumatic check
and rehabilitation surgery like biopsy, puncture and angiography.
     Operation expenses mean expenses for operation items stipulated by local health administration departments,
including operating room charges, anesthesia fees, surgical monitoring fees, auxiliary operation fees, material fees,
disposable supplies fees, intraoperative drug charges and surgical equipment charges.
     (3) Medicine expenses
     Medicine expenses mean expenses for traditional Chinese medicines and Western medicines falling within the
medicine scope stipulated by local administration regulations on social medical insurance.
     (4) Treatment expenses
     Treatment expenses mean technical labor expense, medical equipment charges and consumables fees of the
curing body when providing medical methods to cure diseases, including injection fees, equipment treatment fees,
physiotherapy fees, blood transfusion fees, oxygen charge and ECP charges.
     (5) Care expenses
     Care expenses mean expenses confirmed according to care grades instructed by doctors, including care worker
payment, disinfection fees, medicine dressing fee, companion fee, medicine extracting fee and heating fee.
    (6) Inspection and examination expenses
     Inspection and examination expenses mean medical expenses arising from necessary medical methods taken for
inspection and examination for the purpose of diagnosing diseases, including medical service fee, diagnosis fee,
gynecologic examination fee, X-ray fee, ECG fee, B ultra, EEG, endoscopy, pulmonary function instrument,
molecular biochemical check and routine examinations of blood, urine and stool.
     (7) Special inspection and treatment expenses
     Includes CT, ECT, CDFI, treadmill, Holter ECG, ECG monitoring, intervention treatment, PCR, lithotripsy,
hyperbaric oxygen, externally RF, NMR, hemodialysis and other large-sized and high-expense examination and
treatment items.
     (8) Ambulance expenses
     Ambulance expenses mean expenses for ambulances dispatched by emergency centers to save life and expenses
for using vehicles of hospitals during trans-hospital treatment.
     [Overseas] means the countries or regions outside the People’s Republic of China. If the insured receives
medical treatment in Hong Kong, Macao or Taiwan, such medical treatment is regarded as overseas medical
treatment.
     [Fight] means the fight resulting from the provocative or intentional act of the insured.
     [Drink excessively] means the alcohol content of not less than 100mg in 100ml of blood.
    [Drugs] means the opium, heroin, norodin (ice), morphine, marijuana, cocaine and other addictive narcotics and
drugs for mental sickness that are under the state’s control as specified in the Criminal Law of the People’s
Republic of China, but excluding the medicines containing drug content that are prescribed by the doctor and used as
per doctor’s instructions for disease treatment.
     [Driving under the influence of alcohol] means that after inspection or appraisal, the alcohol content in every
100ml of driver’s blood reaches or exceeds the specific standard at the occurrence of accident and driver’s driving
is recognized as driving after drinking or excessive drinking by the traffic administration department of public security
authority according to law.
     [Driving without valid driving license] means any of the following:
     (1) No driving license;
     (2) Driving vehicles not in conformity with the vehicle types specified on the driving license;
     (3) Driving as a holder of a driving license showing failure in examination;
     (4) (When learning driving) Driving without instructions of the coach taking the same vehicle or not driving
according to the designated time or route.
     [No valid driving permit] means any of the following:
     (1) Not obtaining driving permit;
     (2) Motor vehicle is deregistered according to law;
     (3) Not participating in or passing the motor vehicle safety technology inspection on time according to law.
     [Motor vehicle] means the wheeled vehicles driven or drawn by power sets on roads for carrying people, for
transporting cargoes, or for special engineering operations.
     [Medical accident] means the accidents in which medical institution and its medical staff violate the laws,
administrative regulations and department rules governing medical treatment and health as well as diagnosis,
treatment and care rules in medical treatment activities and negligently results in a bodily damage to patients.
     [Diving] means underwater sports carried out with auxiliary breathing equipment in rivers, lakes, seas, reservoirs
or canals.
     [Rock climbing] means sports such as climbing cliffs, exterior walls of buildings, artificial cliffs, ice cliffs and
icebergs.
     [Expedition] means any actions intentionally putting oneself into dangers, with the knowledge of dangers of
losing life or suffering from injury under some special natural conditions, such as driftage in rivers, climbing
mountains, crossing desert on foot and exploring virgin forest without traces of human presence.
     [Martial Art Contest] means any contest between two or more than two persons, such as judo, karate, tae kwon do,
Sanda and boxing, with or without help of any accessory equipment.
     [Stunt Performance] means the special skills such as equestrianism, acrobatics and animal training.
     [Resignation] means the cancellation or termination of labor relationship between the employer and the laborer,
including termination of labor contract upon its expiry, premature cancellation of labor contract, cancellation or
termination of de facto labor relationship or cancellation or termination by either party of labor relationship without
the consent of the other party, etc, but excluding statutory retirement, retirement for sickness and early retirement.
     [Unearned net premium] Unearned net premium = Net premium × (1 – number of preceding days under
insurance/number of days of insurance period). For the number of preceding days under insurance, one day shall be
counted in case of less than one day.
     Net premium means the premium paid by the applicant less the expenses of the Company for each policy
(including business expenses, agency expenses, taxes, insurance guarantee fund, etc), with the deductions accounting
for 25% of the paid premium.
     [Unearned premium] Unearned premium = Premium × (1 – number of preceding days under insurance/number of
days of insurance period).
    [Full years of age] Full years of age are calculated according to the date of birth indicated in the statutory identity
document.

				
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