Article 2: Joint and several insured
Joint and several insured refers to the only child of the insured under the age of 16 years.Article 3 Coverage
The maximum reimbursement is RMB20,000 per year for each Category A insured person (purely commercial insurance). The maximum amount of reimbursement for each Category B insured (Commercial + Coordinated = both) is RMB20,000 per year. The maximum reimbursement is RMB20,000 per year per Category E (Jointly Insured).Article IV Extended Coverage
Each insured person (excluding the joint and several insured persons) will still be entitled to appropriate benefits in the event of a major medical condition that exceeds the maximum limit of RMB 20,000 yuan. Article 5 Liability Exemption Anyone who has suffered from the following diseases (including children) shall not be insured: malignant tumor, heart disease (cardiac insufficiency class II or above), myocardial infarction, leukemia, hypertension (class II or above), cirrhosis of the liver, chronic obstructive bronchial disease, cerebrovascular disease, chronic kidney disease, diabetes mellitus, aplastic anemia, congenital disorders, mental illness or schizophrenia, Epilepsy, specific infectious diseases, AIDS, sexually transmitted diseases, or those who are hospitalized and on full or half rest.Article 5 Compensation Criteria
(1) Outpatient Provisions: For Category A employees, the insurance company compensates for expenses that meet the requirements of the insurance terms and conditions, and for Category B employees, the insurance company compensates for expenses below the starting line, between the starting line and the cap line, and above the cap line that are not covered by the government. When the accumulated expenses of employees in category B reach the scope compensable by the social health insurance, they should first claim for compensation from the government and then claim for the difference from the insurance company. (2) Outpatient expenses: 1. Drugs, treatment and materials: The insurance company will pay 90% of the expenses incurred by the insured person of category A, with a daily limit of RMB250 yuan. The insurer will pay 50% of the costs incurred by the insured person under Category E, with a daily limit of RMB250. The insurer will pay 100% of the costs incurred by the insured person under Category B, up to the outpatient threshold (RMB800), with a daily limit of RMB200. Costs incurred by the insured person under Category B, between the outpatient threshold and the capped threshold (between RMB800 and 5000) will be covered by the insurer at 50%. The insurance company will pay 50% of the outpatient expenses between the starting line and the ceiling line (RMB800 to RMB5000); the insurance company will pay 100% of the outpatient expenses above the ceiling line (RMB5000 or above), with a daily compensation limit of RMB250. 2. Outpatient Examination Expenses: The insurer will pay 90% of the expenses incurred by the insured person under Category A. The daily compensation limit for multiple examinations is RMB600. The insurer will pay 50% of the cost for the insured person under category E, and RMB600 for multiple tests. The insurer will pay 100% of the cost for the insured person under category B up to the outpatient starting line (RMB800); 50% of the cost for the insured person under category B between the outpatient starting line and the cap line; and 100% of the cost for the insured person above the cap line. The insurance company will pay 100% of the expenses above the cap line, up to 600 RMB for more than one item. 3. Provisions for outpatient medication: One-time outpatient prescriptions for common diseases do not exceed seven days; one-time outpatient prescriptions for chronic diseases do not exceed fourteen days; one-time prescriptions for emergencies do not exceed three days; and one-time prescriptions for discharges and business trips do not exceed fourteen days. 4. The insurance company will compensate 100% of the first outpatient expenses due to accidental injury, with a limit of 250 RMB for outpatient on the same day. The next day will be compensated according to the above stipulated percentage. (C) Hospitalization: If an employee needs to be hospitalized, he/she has to fill in the application form in advance and can be hospitalized after our approval. Otherwise, the Company will refuse to pay the medical expenses. Expenses not covered by social insurance but within the scope of insurance responsibility are compensated by the insurance company according to the following provisions: 1. Drugs, treatment, examination and material costs: The insurance company compensates the expenses of the insured person of category A at the rate of 100%. Among them, the examination fee during hospitalization is limited to RMB2000. The insurance company will pay 100% of the expenses below the hospitalization starting line for insured person of category B. The insurance company will pay 15% of the expenses between the hospitalization starting line and the cap line (RMB10,000) for insured person of category B (85% of which is covered by the government); and 20% of the expenses above the cap line (between RMB10,000 and RMB150,000). Among them, the examination fee during hospitalization is limited to RMB2000. The insurance company pays 50% of the expenses incurred by the joint and several insured persons in Category E. 2. Hospitalization Bed Expenses: Bed expenses for Category A, B and B insured persons will be compensated at a 100% rate, with a limit of RMB70 per person per day. 50% of the bed charge for Category E Jointly Insured Person, with a limit of RMB70 per person per day. (D) Maternity of female workers: Employees need to register for social security according to the requirements of social insurance at the same time to the Tianjin Waiqi registration procedures, our company will be regularly verified. 1. Medical expenses paid in accordance with national family planning regulations and within the scope of insurance liability, after the social insurance payment and within the scope of insurance liability, the insurance company will compensate at a rate of 100%. - Examination fees for pregnant women during pregnancy and childbirth; - Expenses for labor and delivery (excluding baby expenses); - Medical expenses incurred by a married person for an abortion or due to termination of pregnancy Medical expenses incurred for abortion or due to termination of pregnancy, - IUD, removal of IUD, sterilization; - Bed charges: the compensation limit is RMB70 per person per day. 2. Maternity check-up and delivery expenses are claimed uniformly from the insurance company after delivery; medical expenses incurred for abortion or due to termination of pregnancy surgery for married persons are claimed after each occurrence. 3. Maternity insurance is not available to the jointly and severally insured. (v) Emergency Treatment Emergency treatment refers to the following conditions with an emergency stamp on the medical record of the visit: 1) High fever (adult degree, pediatric 39 degrees or more). 2) Acute abdominal pain, severe vomiting, severe diarrhea. 3) Shock of all causes. 4) Coma. 5) Seizures. 6) Severe wheezing, dyspnea. 7) Acute chest pain, acute heart failure, severe arrhythmia. 8) Hypertensive crisis, hypertensive encephalopathy, cerebrovascular accident. 9) Acute hemorrhage from various causes. 10) Acute urinary tract hemorrhage, urinary closure, blood closure, renal colic. 11) Acute poisoning (food or drug poisoning), various accidents (electrocution, drowning, self-strangulation, neck picking). 12) Traumatic brain injury, fractures, dislocations, lacerations, burns, scalds, or other acute trauma. 13) All kinds of poisonous animals, insect bites, acute allergic diseases. 14) Foreign bodies in the five senses, respiratory tract, esophagus, acute eye pain, eye redness and swelling, sudden visual impairment and eye trauma. 15) Diseases of infants under two months. 16) Other critical, emergency and serious illnesses. As long as the employee's illness meets one of these criteria, it will be considered as an emergency, and the insurance company will not pay for it if it does not meet the criteria. (F) Use of imported materials: In the absence of similar domestic medical materials that can be replaced, if the insured person needs to use imported medical materials for outpatient or hospitalization treatment, he/she should seek prior written consent from the insurance company, otherwise the insurance company has the right to refuse payment.Article 6: Scope of Medical Treatment Programs
The costs of medical treatment programs that will not be paid: (1) Service Programs 1. Registration fees, consultation fees, and consultation fees. 2. Expedited examination and treatment fees, special medical service fees (including escort escort, follow up, home, mother and child full service, name surgery additional, quality premium fees, etc.). 3. Medical records, various billing costs. (B) non-disease treatment programs 1. A variety of beauty, fitness programs and some non-functional cosmetic and orthopedic surgeries (such as: the treatment of freckles, age spots, hyperpigmentation, ear piercing, saddle nose, breast augmentation, double eyelid, massage and other projects. 2. A variety of cosmetic, orthopedic (except for the sequelae of polio) and physiological defects in the treatment (such as: cutting armpits, hare lip, stuttering, orthopedic slanting, cutting multiple fingers (toes), circumcision, "O" shaped legs, "X" shaped legs and other surgical projects. 3. A variety of weight loss, fat, height, smoking cessation and other programs. 4. Diagnosis of human body information, computerized selection of the optimal period, fetal gender and fetal development examination (except for perinatal examination of female insured persons) and other diagnostic and therapeutic projects. 5. Various health checkups. 6. Various preventive health care programs. 7. A variety of medical advice (including psychological counseling, health counseling, dietary counseling), medical identification (forensic identification, industrial injury identification, labor identification, medical identification, paternity identification), a variety of predictions (stroke prediction, health prediction, disease prediction) health guidance and other projects. (C) diagnostic and treatment projects and medical materials 1. Application of positron tomography device (PET), electron beam (CT), cell knife, ophthalmic excimer laser therapy device and other large-scale medical equipment for examination and treatment projects. 2. Eyeglasses, dentures, prosthetic eyes, prosthetics, hearing aids and other rehabilitative devices, a variety of self-use health care, massage, monitoring, inspection and treatment of physical therapy equipment (such as: massagers, leather (steel) undershirt, waist, steel head and neck, stomach, kidney, uterus, scrotum, hernia belt, knee belt, testicular band, Shen Gong Yuan Qi bag, hot packs, pressure pulse bag, crutches, wheelchairs, deformed insoles, pillows, cushion, brain The medical equipment. 3. Buried automatic reset defibrillator (ICD). 4. Price authority department regulations can not be charged separately for disposable medical materials. (D) treatment program 1. Various types of organ or tissue transplantation of organ source or tissue source (except skin grafts for burn patients). 2. Other organs or tissues transplantation except kidney, heart valve, cornea, skin, blood vessel, bone and bone marrow transplantation and related surgeries to obtain organ source or tissue source. 3. Orthopedic surgery for myopia. 4. Qigong therapy, music therapy, health care nutritional therapy, magnetic therapy and other complementary therapeutic programs. 5. Helium-neon laser intravascular irradiation (blood therapy), cosmetic dental cleaning, dentures, dental implants, orthodontics, stained teeth treatment, porcelain teeth and other projects. (E) other 1. A variety of scientific research, teaching, clinical verification of the diagnosis and treatment program. 2. All medical expenses in violation of family planning. 3. The treatment of fights, assaults, drunkenness, self-injury, suicide, self-inflicted injuries, drug rehabilitation, sexually transmitted diseases, traffic accidents, medical malpractice and other accidents caused by liability. 4. Medical expenses incurred during the period of going abroad or going to Hong Kong, Macao or Taiwan for family visits, meetings, study tours, further training and lectures. 5. Hospitalized patients should be discharged but refused to be discharged, the medical technology appraisal team to confirm the establishment of the end of hospitalization, from the appraisal of the day after the confirmation of the diagnosis and treatment and all the costs incurred; titled hospitalization or do not meet the criteria for admission to the insured person incurred by the diagnostic and treatment items and all the costs. 6. Medical expenses incurred for health care, rehabilitation treatment (functional) and unauthorized rehabilitation treatment. 7. Diagnostic and therapeutic items that are not included in the price policy. Pay part of the cost of treatment items (a), diagnostic and therapeutic equipment and medical materials 1. The application of X-ray computed tomography (CT), magnetic **** vibration imaging device (MRI), spiral CT (SCT), single-photon emission computerized scanning device (SPECT), single-photon emission computerized tomography (ECT), color Doppler, left ventricular ultrasound (LVT), and the use of the same device, the use of the same equipment and medical materials. Doppler, left ventricular ultrasound three-dimensional color map, dynamic electroencephalograph, ultrasound gastroscopy, intracardiac physiology instrument, 24-hour dynamic electrocardiogram, 24-hour dynamic blood pressure, medical linear gas pedal, and other large-scale medical equipment for examination and treatment items.85% 2. Cardiac and angiographic X-ray machine (including digital subtraction equipment).90% 3. Extracorporeal shock wave lithotripsy, hyperbaric oxygen therapy items, Radiofrequency therapy. 90% 4. All kinds of clinical monitoring (except intraoperative and postoperative monitoring). 90% 5. Stereotactic radiation therapy device Acme knife (X-knife), Gamma Knife (r-knife) photon knife. 70% 6. 70% 6. pacemaker, artificial crystals, artificial joints, artificial larynx, artificial femoral head, artificial valves, artificial blood vessels and other artificial organs replaced in the body, the body placed in the material and the installation or placement of the surgical project, a variety of stents, a variety of anastomoses, a variety of catheters, buried drug delivery device. --90% domestic, 85% Sino-foreign joint venture, 80% imported (B) treatment program category 1. Hemodialysis, peritoneal dialysis program. 95% 2. Cardiac laser perforation, anti-tumor cellular immunotherapy, fast neutron therapy projects, tumor pump drug delivery, T lymphocyte reflux method in tumor biotherapy, prostate electrocision. 85% 3. Cardiac bypass grafting, cardiac catheterization balloon dilatation, cardiac radiofrequency ablation, coronary arteriography, laparoscopic and thoracoscopic surgical procedures projects. 85% 4. A variety of microwave, frequency universal, Far infrared rays, light quantum (liquid therapy) and other auxiliary treatment programs. 85% 5. Perform kidney, heart, cornea, skin, blood vessels, bone, bone marrow transplantation surgery program. 90% 6. Diabetes decision support system, sleep respiratory monitoring system, micronutrient monitoring, bone densitometry 80% 7. Anesthesia post-surgical analgesia new technology (pain bed), endoscopic retrograde appendicography and other diagnostic and therapeutic items. 50% 8. Microwave (radiofrequency) treatment of prostate hyperplasia, various imaging tests. 50% Note: The compensation for the above partially paid items Note: The percentage of compensation for the above partial benefit items is limited to the percentage of compensation not exceeding the prescribed outpatient expenses or hospitalization expenses. Scope of non-payable medical service facilities Referral transportation fee, emergency vehicle fee, air-conditioning fee, heating fee, TV and telephone fee, electric stove fee, refrigerator fee, warming box fee, compensation for damage to public property, caregiver fee (escorting, accompanying the bed), cleaning fee, outpatient decoctions, traditional Chinese medicine processing fee, meals, recreational activities, newspapers and magazines, fitness activities, sanitary tableware, washbasins, mouth cups, Toilet paper, bed sheets, pillow cases, bed towels, diapers, garbage bags and other disposable items and other special living services.Article 7: Claims:
(1) Application for insurance benefits Outpatient: 1. Claim application form (please fill in the form separately for the employee and the child) 2. Copy of outpatient medical records (if necessary, the insurance company has the right to request the insured to provide the originals): containing the main symptoms, diagnosis, and diagnostic and therapeutic opinions: the medication should be Contain: medicine name, dosage, usage, total amount, etc.; 3. Copy of various examination reports (if necessary, the insurance company has the right to request the insured to provide the originals); 4. Copy of prescription and the original list of outpatient medicines (if necessary, the insurance company may request the originals); 5. The original medical receipts, please provide the red receipts and the blue receipts, and provide the reimbursement of the children's expenses if they are reimbursed by multiple parties. For multi-party reimbursement, please provide proof of the amount reimbursed by the reimbursing party and a copy of the receipt. For Category B employees, please provide a copy of the medical receipt and the original of the payout list after claiming from the government, and the insurance company has the right to request the insured to provide the original receipts if necessary. 6. Any other documents that the insurance company deems necessary, such as examination films, original information, etc. Hospitalization: 1. A copy of the outpatient medical record at the time of admission (if necessary, the insurance company has the right to request the insured to provide the original); &n