China Life Insurance Company Group Comprehensive Medical Insurance Provision
Article 1: Insurance Contract Group comprehensive medical insurance (hereinafter the attached contract) is the attachment of group life insurance contract (hereinafter the major contract). Items, which are not stated in the attached contract, shall conform to the major contract. The attached contract will lapse with the lapse of the major contract. And if the major contract is invalid, the attached contract will be invalid, too. If any contradictions between the major contract and the attached contract exist, the major contract shall prevail. Article 2: Eligibility A. Those, who are less than 65 years old, and healthy, can be the insured, and the employer can be the policyholder. When the employer applies for the policy, more than 75% of the employees must be covered. And the number of the insured must be over 8 people. With the approval of the insurer, the spouse and the children of the insured also can be covered as the joint insured. The policyholder shall coordinate the application. B. Those, who suffer the following diseases before covered by the policy, will not be eligible to be covered as the insured or the joint insured: malignant tumor, heart disease ( above cardiac functional insufficiency II degree ), myocardial infarction, leukemia, hypertension ( above II stage ), cirrhosis, chronic obstructive bronchial diseases, cerebrovascular diseases, chronic kidney diseases, diabetes, aplastic anemia, congenital diseases, mental diseases, schizomania psychosis, epilepsy, specified infectious diseases, AIDS, venereal diseases, are hospitalized, or have a complete or half rest. Article 3: Insurance Liability A. During the validity of the contract, the outpatient medical expenses occurred, when the insured or the joint insured fall sick or get injured by accidents, including drug expenses, treatment expenses, examination expenses, and material expenses, can be reimbursed at the proportion from 50% to 100% by the insurer. The accurate reimbursement rate shall be defined when the policyholder applying for the policy. B. During the validity of the contract, the inpatient medical expenses occurred, when the insured or the joint insured fall sick or get injured by accidents, including drug expenses, treatment expenses, examination expenses, material expenses, and daily room, for which the utmost limit is RMB200 per day, can be reimbursed at the proportion from 15% to 100% by the insurer. The accurate reimbursement rate shall be defined when the policyholder applying for the policy. C. During the validity of the contract, the following expenses occurred by the female insured, on condition that the expenses are in accordance with the national
family planning policy: 1. expenses for gravid perinatal examination; 2. expenses for maternity (excluding the infant’s expenses); 3. medical expenses of the married caused by stopping pregnancy measures, such as abortion and induced abortion. The insurer will compensate within the limit of RMB8,000, which will not be taken in the account of the insured amount. D. Except emergency treatment, if there is any single-item outpatient examination exceeding RMB200, or any single-item inpatient examination exceeding RMB300, the insurer should be informed first and the insurer’s approval must be gained, otherwise, the insurer has the right to reject the compensation. Emergency and the examination and lab test item approved will be compensated within 10% of the insured amount per time. E. During the validity of the contract, no matter how many times the outpatient or inpatient medical expenses in the scope of insurance liability may occur to the insured or the joint insured, the insurer shall make the compensation according to the above standards. Once the accumulated compensated amount reaches the total insured amount, the insurance liability to the insured or the joint insured will terminate simultaneously. F. In the case that the policyholder has chosen the liability of public shared insured amount, during the validity of the contract, and the insured amount in the insured or joint insured’s personal account has been used up, with the approval of the policyholder, the insurer can compensate according to Rule A, B and C of Article 3. However, this compensation shall not exceed the public shared insured amount in the policyholder’s account. Article 4: Exclusion The insurer will not be liable to the medical expenses, if it is aroused due to the following situations: 1. conditions listed in the exclusion provision of the major cover; 2. non-treatment actions of the insured or joint insured, such as health care; 3. the insured or the joint insured treats in restoring hospital, allied clinics, hospitals run by the local, private clinics, homely bed, titular bed etc.; 4. the insured or the joint insured has toothwash, dental brush, face-lifting, orthopadics, eyesight tested for glasses, ocular prosthesis, dental prosthesis, artificial limb, or audiphone; 5. the insured or the joint insured gets AIDS, mental disease, and schizophrenia; 6. treatment and healthcare caused by the diseases or dismemberment contracted before the insured or the joint insured member is covered by the insurance; 7. the insured or joint insured is treated in hospitals, which are not designated or approved by the insurance company; 8. the insured or the joint insured transfers to another hospital for treatment without the approval of the insurance company; 9. MRI or taking medicines when discharge;
10. medical expenses occurred outside of Mainland China, in Taiwan, HongKong, and Macao; Article 5: Designated Hospital The insured or the joint insured can choose any of the designated hospitals offered by the insurer to be treated. If the condition of the designated hospital is limited, and the insured or the joint insured need transferring to a non-designated hospital, a group consultation must be held by the designated hospital first, and the transfer certificate and the approval of the insurer shall be gained. The insurer will be liable to pay the compensation. When the insured or the joint insured need treatment due to emergency, he can be treated in non-designated hospitals. And the insurer will be liable to pay the compensation. If the designated hospitals overcharges or violates the rules of the local social medical administration department, the insurer is entitled to cancel this designated hospital and notifies the policyholder, the insured, and the joint insured. Article 6: Insurance Period The insurance period of the contract is 1 year. After the termination of the contract, the policyholder can apply for the insurance again, and pay the premium according to the regulation. The insurer will issue a new policy. When the policyholder re-applying, the insurer is eligible to adjust the premium.
Article 7: Insured Amount and Premium A. The minimum insured amount for the insured is RMB10,000, and the maximum is RMB100,000.The minimum insured amount for the joint insured is RMB10,000, and the maximum is RMB50,000. B. The annual premium paid by the insured or the joint insured shall be decided by the insured amount and the insurance liability chosen. C. The policyholder can exact the public shared insured amount with the insurer, which will not be recorded in any insured or joint insured’s personal account. During the validity of the contract, if any insured or joint insured has used up his personal account, he can apply for the employment of the public shared insurance amount with the approval of the policyholder. Article 8: Utmost Faith When signing the contract, the insurer shall illustrate the provisions to the policyholder clearly, especially the exclusion provision. And the insurer is eligible to submit the written inquiry concerned with the policyholder, the insured or the joint insured. The policyholder, the insured or the joint insured shall tell the truth. If the policyholder, the insured or the joint insured acts against the utmost faith principle intentionally, the insurer is eligible to terminate the contract, not liable for the insured event, which happens before the termination of the contract, and will not
refund the premium. If the policyholder, the insured or the joint insured acts against the utmost faith principle by negligence, which is serious enough to make the insurer to reconsider whether to underwrite or increase the premium rate, the insurer is eligible to terminate the contract. On the condition that the insured event is seriously affected, the insurer will not be liable for the insured event occurred before the termination of the contract, but will refund the premium, which has not expired. Article 9: Beneficiary The beneficiary of the medical compensation is the insured or the joint insured himself. The insurer will not accept any other designation or change. Article 10: Notification of the Insured Event The policyholder, insured, or the joint insured shall inform the insurer of the insured events in 60 days in written notice since the treatment is finished. Otherwise, the policyholder, insured, or the joint insured shall be responsible for the investigation and research fairs caused by the delay, except that the delay is caused by the force majeure. Article 11: Claim of the Compensation A. If the insured or the joint insured has disbursed any medical expenses, as the applicant, the insured or the joint insured shall fill in the application form, and claim with the following certificates and documents against the insurer: 1. insurance policy of the major contract and the attached contract; 2. residency permit or the ID card of the insured or the joint insured; 3. receipts, diagnosis, and medical record issued by the designated hospitals preferred by the insurer; 4. other certificates and documents the insured or the joint insured can offer to affirm the character, cause and degree of the insured event. B. After the insurer receives the claim application and documents, affirms that is included in the insurance liability, and reaches agreement with the applicant on the indemnity amount, the indemnity will be payable within 10 working days. If the event is excluded, the insurer will notify the applicant of the rejection. C. Within 60 days since the insurer receives the claim application and documents, under the circumstance that the event is covered by the insurance liability, but the indemnity amount cannot be affirmed, the insurer will pay the minimum indemnity assured first, and pay the difference after the indemnity amount is affirmed finally. D. The claim right of the insured or the joint insured will diminish in 2 years since he acquaints or shall acquaint the occurrence of the insured events. Article 12: Modification of the Contract During the validity of the contract, with the agreements of the policyholder and the insurer, the contract can be modified. When modifying, the insurer shall annotate in the original policy or issue the endorsements attached. If the government changes
the social medical insurance policy, which makes modifying the contract necessary, the policyholder and the insurer sign the written agreements on the modification. Article 13: Policyholder Terminating the Contract After signing the contract, the policyholder can require to terminate the contract. A. When applying, the policyholder shall submit the following certificates and documents: 1. insurance policy; 2. premium receipts; 3. application letter of the termination. B. When the policyholder requires terminating the contract, the insurance liability will terminate since the insurer receives the application. The insurer will refund the premium, which has not expired, within 10 working days since the above-mentioned certificates and documents are received. C. In the circumstance that the compensation has been paid, the policyholder cannot require terminating the contract. D. If the termination is caused by the government adjusting the social medical insurance policy, it is not regulated by Rule C of this Article. Article 14: Change of the Insured or the Joint Insured During the validity of the contract, the change of the insured or the joint insured will be handled according the following rules: A. The policyholder shall notify the insurer in written form within 30 working days counting from the date that the insured begins to work. The insurance liability will effect automatically from the beginning working date of the insured. Otherwise, the insurer will underwrite the newly enrolled insured since the notification is received. The insurer will sign and issue the endorsement, which will be taken as the appendix of insurance policy according to the written notification, and increase the premium according to the actual insurance days. B. The enrollment of the joint insured caused by the enrollment of the insured will be handled according to Rule A of this Article. C. The policyholder shall notify the insurer in written form within 30 working days counting from the date that the insured quits. The insurance liability will lapse on the date of his quit. Otherwise, the insurer will terminate the liability to the insurer since the notification is received. The policyholder shall notify the insurer in written form, the insurer shall sign and issue the endorsement, which will be taken as the appendix of insurance policy, and return the premium which is not expired according to the actual insurance days D. The quit of the joint insured caused by the quit of the insured will be handled according to Rule C of this Article. E. The premium adjustment caused by the change of the number of the insured or the joint insured will be settled at the end of insurance year by the policyholder and the insurer.
Article 15: Dispute During the operation of the contract, if any disputes occur, the two parties shall talk them over to solve the problem. If no agreements made, the matter can be settled by the legal effective arbitrary agreements. No arbitrary agreements or no effective agreements made, the matter can be submitted to the court, which is in charge of the issuing place of the policy. Article 16: Definition Premium, which has not expired = annual premium x (12- months passed)÷12. The days, which have not reached 30 days, will be estimated as a month. Actual Premium = annual premium x actual months covered÷12. The days, which have not reached 30 days, will be estimated as a month. Out of the territory of China: countries and areas, which are not within the boundary of People’s Republic of China. Force Majeure: the objective occurrence that cannot be predicted, avoided, and got over. Accident: the external, sudden, non-intentional, non-diseased and objective occurrence, which injures the insured physically. Drug Expense: expenses of traditional Chinese medicine, Western medicine, and synthetic Chinese medicine. The extent of the drugs shall conform to the regulation of the local governmental medical administration department. Treatment Expense: ① Regular treatment expenses: intramuscular injection, intravenous injection, venous transfusion, subcutaneous injection, hemospasia, skin test, dressing change, traction, decompression of stomach or intestines, spray inhalation, electrocardiographic monitoring, physiotherapy, blood transfusion, emergency treatment, and oxygen. ② Anesthesia & operation: expenses of operation, anesthesia operation, anesthesia instruments, anesthesia material, and dope. ③Special treatment expenses: radiotherapy, chemotherapy, insert therapy (SK, 扩 冠 , radio frequency), external counterpulsaton, hemodialysis, and peritoneal dialysis. ④Special handling expenses: handling of operation room and instruments, and infectious disease sterilization. Examination expenses: including regular examination (lab test, X-ray, ECG), and special examination (CT, B ultrasonoscopic method, HOTTER, gastrofiberscope, bronchoscope, enteroscopy, rectal speculum, and esophagoscope). Material expenses: Expenses of common materials: including dressing, iodine
tincture, alcohol, drain, thoracic bondage, stomach tube, urinary catheter, disposable articles, electrode plate, and venipuncture needle. Enpenses of special materials: home-made medical materials (artificial joints and vavle), fixed orthodontic appliance, prosthesis, speculum tube, insert treatment tube, contrast medium, blocking, and SK. The insurer shall only be liable to the home-made above mentioned materials. And only with the approval of the insurer, the insurer shall be liable to the employment of the imported matrials. AIDS: the abbreviation of Acquired Immunity Deficiency Syndrome. The definition shall conform to the definition issued by WHO. If in the sample of blood HIV or other antibody is found, one can be regarded that he has infected AIDS or HIV. Congenital disease: the disease (syndrome or physical sign) acquired when the insured was born. These diseases are caused by the malignant changes of genetic material (including chromosome and gene contained), or internal or external physical, chemical, and biological effects during the period of pregnancy, which causes partial cells’ abnormal growth and the organs and systems concerned are abnormal in appearance or function, when the infant was born. Specific infectious disease: refers to the sudden attack of the following official infectious disease. Type A: the plague, cholera, paracholera, and smallpox. Type B: diphtheria, epidemic cerebrospinal meningitis, dysentery (bacillary dysentery and amebic dysentery), typhoid, paratyphoid, virus hepatitis, malaria, typhus, recurrent fever, black sickness, forest spring encephalitis, shashitsu, hemorrhagic fever, leptospirosis, and brucelliasis. Emergency: refers to the first treatment of the following cases: high fever (adult above 38.5, child above 39); acute abdominal pain, serious vomiting, serious diarrhea; kinds of shocks; coma; epileptic attack; serious breathing spell, difficult breathing; acute chest pain, acute heart failure, serious arrhythmia cordis; hypertension, hypertension brain disease, cerebral accident; different acute haemorrhage; acute urethrorrhagia, metrorrhagia, renal colic pain; different acute poisoning (food or medicine poisoning), different accident (electroshock, commit suicide, drown) ; brain trauma, fracture, dislocation, laceration, burn, scald, or other acute trauma; bite by different poison animal or insect, acute hypersensitivity disease; foreign body in facial features, breathe system and esophagus, acute eye-ache, red and swollen, suddenly eye sight dysfunction and eye trauma; two months old baby’s disease; other serious disease.