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Individual Hospitalization Medical Insurance Terms
Article I: Composition of the Insurance Contract
This insurance contract (hereinafter referred to as this contract) consists of the insurance policy or other insurance certificates and the terms and conditions attached thereto, the application form, the application documents related to this contract, the health notification, the statement, the endorsement, the attached endorsement, and other written agreements.
Article II: Scope of Insurance
I. Scope of Insured: All urban and rural residents who are over one year of age and under sixty years of age and in good health are eligible to participate in this insurance as insured.
Scope of insured: The insured himself/herself or any other person who has insurance interest in the insured can be the insured and take out this insurance with New China Life Insurance Company Limited (hereinafter referred to as the Company).
Article 3 Insurance Liability
1. During the validity period of this contract, if the insured person is hospitalized in a designated hospital due to accidental injury or illness after 60 days from the effective date of the contract (except for renewal of the insurance), the Company shall bear the insurance liability in accordance with the following agreements:
1. Hospitalization Expense Benefit: Hospitalization Expense Benefit shall be paid according to the actual hospitalization bed expense of the insured person, with a daily limit of RMB 20 yuan. The daily benefit limit is 20 yuan, and the maximum number of days for each hospitalization is one hundred and eighty days.
2. Hospitalization Miscellaneous Expenses and Surgical Expenses Benefit: For the miscellaneous expenses and surgical expenses incurred by the insured person due to each hospitalization, the Company will pay the insurance benefit for the portion of the miscellaneous expenses and surgical expenses exceeding RMB 400 in accordance with the proportion specified in Schedule II. In other words, the Insured Person shall pay $400 out-of-pocket for each hospitalization for Miscellaneous and Surgical Expenses, and the Company shall be liable to pay only the portion of the Benefit in excess of $400. Miscellaneous and surgical expenses refer to: general nursing care, medicine, treatment, diagnosis, examination, laboratory, radiology, anesthesia, blood transfusion, oxygen, materials, and surgery.
2. During the validity period of this contract, regardless of whether the insured person has been hospitalized for one or more times, the Company shall pay the insurance premiums according to the provisions of the first paragraph of this article, and the validity of this contract shall be terminated when the total amount of insurance premiums paid reaches the full amount of insurance premiums.
Article 4 Exemption of Liability
The Company shall not be liable to pay the hospitalization medical expenses incurred by the insured due to any of the following circumstances:
I. The policyholder intentionally causes the insured to be injured or hospitalized;
II. The insured intentionally commits a crime or refuses to be arrested;
III. The insured is engaged in a fight, is intoxicated, commits suicide, intentionally injures himself or herself, or takes, smokes, or uses drugs. Self-injury and taking, smoking or injecting drugs;
IV. Accident caused by the insured person being under the influence of alcohol, drugs or controlled substances;
V. Driving under the influence of alcohol, driving without a license and driving a motorized transport vehicle without a valid license;
VI. Diseases, congenital diseases and hereditary diseases existing prior to the date of taking out the policy;
VII, The period during which the insured person is diagnosed with AIDS or HIV (HIV-positive);
VIII. The insured person's pregnancy, abortion, miscarriage, childbirth, birth control, and the resulting damage or illness;
IX. Cosmetic surgery, surgical reconstruction, correction of birth deformities, dental treatment and surgery;
X. The purchase of a transplanted organ, the installation of an artificial organ, the purchase of a wheelchair, a heart attack, the purchase of an artificial organ, the purchase of a wheelchair, or the purchase of a heart attack. artificial organs, purchase of wheelchairs, pacemakers, hearing aids and prescription glasses;
XI, the insured person engaging in high-risk sports such as scuba diving, parachuting, rock-climbing, adventure activities, martial arts competitions, wrestling competitions, stunts, horse racing, car racing and other high-risk sports;
XII, war, military operations, riot or armed rebellion;
XIII, nuclear explosion, nuclear radiation or nuclear pollution and the resultant sickness;
XIII, nuclear explosion, radiation or nuclear pollution and the resultant sickness;
XIII. consequential diseases;
xiv. General physical examination, convalescence, rehabilitation treatment, special care or retreat;
xv. Medicines, examinations, surgeries, treatments, and other items that are required to be paid for at one's own expense as stipulated by the Social Medical Insurance Administration;
xvi. Medical fee items not approved by the Health Administration.
Article 5: Period of Insurance
The insurance period of this contract is one year, starting from zero hour of the day following the day when the Company agrees to underwrite, collects premiums and issues the insurance policy, and ending at twenty-four hours on the agreed termination date.
Article VI: Insurance Amount and Premium
I. The minimum insurance amount of this contract is RMB 10,000 yuan, and once the insurance amount is determined, it cannot be changed during the insurance period.
2. The premium of this contract shall be paid in accordance with the Individual Hospitalization Medical Insurance Rate Table (see Exhibit I for details) according to the age of the insured person and shall be paid in one lump sum at the time of enrollment.
Article 7 Renewal
I. Upon the expiration of the insurance period, the policyholder may renew this insurance upon application and approval by the Company.
The renewal premium shall be calculated at the rate corresponding to the age at the time of renewal and shall be paid in one installment.
3. The Company reserves the right to adjust the premium rate of this insurance, and the adjusted premium rate will be notified to the policyholder and will be applicable from the renewal of the policy.
Fourth, the insured person is hospitalized during the insurance period and has not been discharged from the hospital until the expiration of the insurance period, if the Company agrees to renew the insurance, the insured person shall bear the insurance responsibility for the hospitalization medical expenses according to the actual time of occurrence under the original policy and the new policy respectively; if the Company does not agree to renew the insurance, the Company shall bear the responsibility of paying the insurance benefit for the hospitalization medical expenses incurred in the first month of the insurance period in accordance with the provisions of the Article 3, and the accumulated insurance benefit shall be paid in full. The Company shall still bear the responsibility of paying the insurance benefit according to the provisions of Article 3 for the hospitalization medical expenses incurred within one month after the expiration of the insurance period.
Article 8: Truthful Notification
When concluding this contract, the Company shall clearly explain to the policyholder the contents of the terms of this contract, in particular the exemption of liability clauses, and may make written inquiries regarding the relevant circumstances of the policyholder and the insured, who shall be required to truthfully notify the Company of the contents of this contract.
If the policyholder or the insured intentionally fails to fulfill the obligation of truthful information, the Company has the right to terminate this contract and shall not be liable to pay the insurance benefits or refund the insurance premiums for the insurance accidents that occurred before the termination of this contract.
If the policyholder or the insured fails to fulfill the obligation of truthful notification due to negligence, which is sufficient to affect the Company's decision on whether to agree to underwrite the insurance or to increase the premium rate, the Company has the right to terminate this contract; if it has a serious impact on the occurrence of insurance accidents, the Company shall not be liable for the payment of insurance premiums and shall refund the unexpired premiums after deduction of the handling fee for the insurance accident which occurs prior to the termination of this contract.
Article IX Beneficiary
The beneficiary of the insurance benefit of this contract shall be the insured himself, and the Company shall not accept any other designation or change.
Article 10: Notification of Insurance Accident
The policyholder and the insured shall notify the Company within ten days from the date when they know or should have known of the occurrence of the insurance accident. Otherwise, the policyholder and the insured shall be responsible for the additional costs of investigation and inspection incurred by the Company due to the delay in notification, except for the delay caused by force majeure.
If the insured person seeks medical treatment in a non-designated hospital, prior consent of the Company shall be required, otherwise the Company shall not be liable for the insurance.
Article 11 Application for Insurance Benefits
1. If the insured person incurs the payment of medical expenses within the scope of insurance liability, the insured person, as the applicant, shall fill in the application form for insurance benefit payment within thirty days after the insured person is discharged from the hospital and apply for the payment of insurance benefits to the Company with the following certificates and information:
1. Insurance policy and proof of payment;
2, Certificate of the insured's household registration and proof of identity;
3. Medical diagnosis issued by the Company's designated hospital (stating the full name of the diagnosis, brief medical history and course of treatment) as well as original certificates of hospitalization medical expenses, billing details and prescriptions;
4. Other certificates and information related to the confirmation of the nature of the insurance accident, the cause, and extent of the injury, etc.
5.
2. Upon receipt of the application for payment of insurance premiums and the above proofs and information, the Company shall fulfill its responsibility of paying insurance premiums within ten days after reaching an agreement with the applicant on the amount of insurance premiums if it is determined to be an insurance responsibility. If it does not belong to the insurance responsibility, the applicant shall be issued a notice of refusal to pay the insurance benefit.
3. The insured's right to request the payment of insurance benefits from the Company shall be extinguished if it is not exercised within two years from the date when he/she knew or should have known about the occurrence of the insurance accident.
Fourth, if the claim is made by an agent, a letter of authorization from the principal and proof of identity of the agent shall be provided.
Article 12: Determination of Age and Handling of Errors
I. The age of the insured is calculated in weeks.
2. When the policyholder applies for the insurance, he/she shall fill in the true age of the insured in the policy, and if there is any mistake, it shall be handled in accordance with the following provisions:
1. If the age of the insured declared by the policyholder is untrue and his/her true age does not comply with the age limitation agreed in this contract, the Company may terminate the contract, and refund the premiums to the policyholder after deduction of the handling fee.
2. If the age of the insured declared by the policyholder is untrue and the actual premium paid by the policyholder is less than the premium payable, the Company shall have the right to correct the situation and require the policyholder to pay the premiums; if an accident occurs, the Company shall pay the premiums according to the ratio of the actual premiums paid to the premium payable at the time of the payment of the insurance benefits.
3. If the age of the insured person declared by the insured person is not true, and the premium paid by the insured person is more than the premium payable, the Company shall return the overcharged premium to the insured person.
Article 13 Change of Address
The policyholder shall promptly notify the Company in writing of any change in his/her domicile or correspondence address. If the policyholder fails to notify the Company in writing, the Company shall send a notification to him/her at his/her last domicile or correspondence address as specified in the present contract.
Article 14: Changes in the contents of the contract
During the period of validity of this contract, the contents of this contract may be changed by agreement between the policyholder and the Company. In case of change of this contract, the Company shall endorse or attach an endorsement to the original insurance policy or other insurance certificates, or the policyholder and the Company shall enter into a written agreement on the change.
Article 15: Termination of this contract by the policyholder
If the policyholder does not wish to continue the insurance after the inception of this contract and no insurance benefit has been paid, the policyholder may request the termination of this contract by written notice.
I. When the policyholder requests to terminate this contract, he/she shall provide the following certificates and information:
1. insurance contract;
2. premium receipt;
3. application for termination of the contract;
4. proof of identity of the policyholder.
2. If the policyholder requests to terminate the contract, the insurance liability will be terminated from the date the Company receives the notice of contract termination, and the Company will refund the unfulfilled premiums after deducting the handling fee within 30 days from the date the Company receives the above mentioned certificates and information.
Article 16 Dispute Settlement
Disputes between the two parties in the course of the fulfillment of this contract shall be resolved through negotiation; if no agreement is reached through negotiation, litigation may be instituted in the People's Court of the place where the insurance policy is issued.
Article 17 Interpretation
Designated hospital: means the public hospitals above district and county level designated or agreed by the Company.
Hospitalization: means the insured person is admitted to the official ward of the hospital designated by the Company for treatment due to illness or accidental injury and is formally admitted and discharged from the hospital, excluding admission to outpatient clinics, emergency observation rooms, other unofficial wards, or hospitalization in a registered bed.
Sickness: refers to the sickness suffered after the 60th day of the effective date of this contract (except for the renewal of the policy on a regular basis).
Accidental Injury: means an external, sudden, unintentional, non-disease objective event that causes bodily injury.
AIDS: is short for Acquired Immune Deficiency Syndrome.
AIDS: is short for Acquired Immune Deficiency Syndrome Virus. The definition of Acquired Immune Deficiency Syndrome shall be as established by the World Health Organization, and a person shall be recognized as being infected with AIDS or HIV if the Acquired Immune Deficiency Syndrome virus or antibodies to it are found in a blood sample.
Diving: is an underwater sport practiced in rivers, streams, lakes, seas, reservoirs, canals, and other waters with assisted breathing apparatus.
Rock Climbing: is the sport of climbing cliffs, building facades, man-made cliffs, ice cliffs and icebergs.
Martial arts competition: refers to two or more people against judo, karate, taekwondo, sanshou, boxing and other kinds of boxing and all kinds of use of equipment confrontational competition.
Exploration activities: refers to know that in a particular natural conditions, there is a risk of loss of life or physical injury, but deliberately put themselves in the behavior. Such as river rafting, hiking through the desert or rare primitive forests and other activities.
Stunts: refers to engage in equestrian, acrobatics, animal taming and other special skills activities.
Force majeure: refers to objective circumstances that cannot be foreseen, avoided and overcome.
Unexpired Premium: It is the premium x (12 - the number of months that have passed in this contract) ÷ 12, and if less than one month, it is calculated as one month.
Processing fee: 25% of the unfulfilled premium.