保险具体内容及介绍

投保单位:

APPLICATION COMPANY:

人:

APPLICANT:

护照号码:

PASSPORT NO.:

第一部分保障项目

保障内容简表:

Insurance contents table

Accidental Injury Insurance

coverage

Insured Sum

accidental and disease death

RMB225000

accidental disability

RMB200000

In-patient Medical Insurance

coverage

Medical Expenses

In-patient medical expenses

RMB400000

Traffic Accidental Insurance

Coverage

Insured Sum

Accidental Death

Airplane RMB200000, Train and Steamboat RMB100000, automobile RMB50000

Accidental Disability

Accidental In-patient Allowance

Coverage

Insured Sum

In-patient Allowance

RMB100/day/person

Accidental Medical Insurance

Coverage

Insured Sum

Accidental Medical

RMB10000

the service manual shall not be referred as insurance certificate, the issured policy shall prevail. We shall issue the policy and invoice.

服务指南

Service guide

为更好的保障来华人员在遭受意外或疾病困扰时的经济利益,您参加了在平安养老保险股份有限公司江苏分公司承保的人身保险和意外医疗保险,以下是关于保险内容的介绍及服务指南。

For guranteeing the economic benefits for the foreigner who came to china when suffering from disease, you join in the insurance plan of life insurance and accidental medical insurance, the insurance contents and service guide shall be shown as following:

一、保险期间 insurance term

具体以您参保后,签发的保险单上载明的时间为准

Please refer to the time listed in the policy issued by our company after your application.

二、参保资格 qualification

所有身体健康、能正常工作和生活的16-60周岁来华人士。(0~17周岁收费标准为100%61~70周岁收费标准为150%,71~75周岁收费标准为200%)

The insured is the visitor from abroad aging from 16 to 60 who is healthy and capable of normal workand normal living (charged by the rate of 100% for the insured who is aging from 0 to 17 years old, by the rate of 150% upon the basic premiums for those who are aging from 61 to 70, and by the rate of 200% upon the basic premiums for those who are aging from 71 to 75 years old.).

三、参保手续application

由各单位统一办理参保手续。The institution shall handle with application procedure respectively.

四、受益人 beneficiary

医疗保险金的受益人为参保人本人,身故保险金的受益人为参保人员的法定继承人。The beneficiary of medical benefits shall be the applicant, and the beneficiary of death benefits shall be the heritor in law of the applicant.

五、服务热线 service hotline

平安养老保险股份有限公司江苏分公司服务专员(王碧云)热线:0258467728313809045696

Service commissioner of Ping An Annuity Insurance Company, LTD, Jiangsu Branch (Biyun Wang)

Service tel: 0258467728313809045696

六、就诊指定医院 designated hospital

1)指定医院为当地社会基本医疗保险部门定点的区县级以上公立医院。意外急诊首诊可以到非指定的区县级以上的公立医院就诊治疗;The designated hospitals are those public hospitals over district (county) designated by the local medical insurance department. If needing an accidental and emergency treatment, the non-designated public hospital can be chosen.

2)所指定医院的分院、外宾病区、特诊病区、特诊病房和高干病房等同类病区或病房不在指定的范围内;The branch of designated hospital, foreigner hospitalization area, special treatment area, special treatment room and joint venture and exclusive investment room (hospital) are not in the regulated scope;

七、用药范围:Medicine

为了切实保证来华人员获得最充足的保障,本方案医疗药品报销范围按以下相关规定执行:《南京市基本医疗保险药品目录》for the complete guarantee, the medical scope of the insurance plan shall refer to the regulation of Medicine List of Basic Medical Insurance in Nanjing.

八、意外门急诊范围包括:The scope of accidental out-patient and emergency treatment shall be as following:

1)因意外原因造成的休克、昏迷。Shock, coma caused by accident;

2)因意外原因所致急性出血。 Emergency bleeding caused by accident;

3)脑外伤、骨折、脱位、撕裂、烧伤、烫伤或其他急性外伤。Brain trauma, fracture, dislocation, avulsion, burn or other acute trauma;

九、索赔 claims

1、索赔手续:被保险人申请医疗费赔偿时,先填写《保险理赔申请书》一份并加盖公章,然后将资料交至保险公司服务人员。Claims procedure: when the insured applies with medical expenses claims, he/she should fill in insurance claims application with the seal, and then give the relative materials to the service commissioner of insurance company.

2、理赔时限:保险公司收取理赔资料后,在15个工作日内完成理赔,并将理赔款项直接打入被保险人个人帐户,或被保险人直接到柜面领取Claims effectiveness: after taking the claims application, insurance company should finish claims within 15 working days and transfer the indemnity into the individual account of the insurer, or the insured can draw the benefits to the counter directly.

3、索赔时须提供的单据:The materials when claiming

住院或意外门诊保险金的申请the out-patient or in-patient benefits application

由被保险人作为申请人,填写保险金给付申请书,并凭下列资料向保险人申请给付保险金:the insured fills in the benefits claims application as the applicant and applies with the benfits with the following materials:

1)、保险单或其他保险凭证及保险金申请书;Insurance policy or the other insurance documents;

2)、被保险人身份证明;ID certificate of beneficiary;

3)、本补充约定指定或者认可的医疗机构出具的医疗费用原始收据、电脑打印的费用明细清单、意外门急诊病历复印件、出院小结;Duplicated documentation of the case history, diagnosis certificate, brief summary of leaving hospital, prescription and the original certificate of medical expenses issued by the hospital;

4)、被保险人所能提供的与确认保险事故的性质、原因、伤害程度等有关的其他证明和资料;Any other certificates and documents can be provided to prove the nature and cause of the insurance accident;

注:不受理外配药发票及到药房自行购买的药费发票;Remarks: the medicine invoice bought in drug store or in the other hospital shall not be included in.

十、索赔时效: Time limit of claims

1、被保险人申请住院或意外门急诊医疗赔偿时,应在三个月内提出索赔,否则,可能会带来的不利法律后果由被保险人自行承担。The insured should apply with in-patient or out-patient and emergency medical benefits within 3 months, or possible result in low shall be undertaken by the insured.

十一、索赔时须注意事项:Notes when claims

1、病历上注明病情、检查、治疗、用药及剂量;病历上的记录与收据上的收费的项目相符;病历上的诊病日期须与收据上的日期一致。The information about case condition, inspection, treatment, medicine and dosage should be identified in the case history; the charged project in the receipt should be the same as the record in the case history; the date receiving treatment in the case history should be the same as that in the receipt.

第二部分 名词释义

Part Two explanation

一、保险责任insurance liability

1.意外身故保险:accidental death insurance

被保险人在本保险有效期间内因遭受意外事故,并自事故发生之日起一百八十日内因该事故身故的,保险人按其保险金额给付意外身故保险金,对该被保险人的保险责任终止。In case the insured suffers from accidental injury and dies within 180 days from the day when the accident happens, the insurer shall pay accidental death insurance benefits upon the insurance amount and the insurance liability shall be terminated.

2.意外残疾保险:accidental disability

被保险人在本保险有效期间内因遭受意外事故,并自事故发生之日起一百八十日内造成条款所附“残疾程度与给付比例表”所列残疾程度之一者,保险人按该表所列比例乘以其保险金额给付“意外残疾保险金”。如治疗仍未结束的,按事故发生之日起第180日的身体情况进行残疾鉴定,并据此给付意外残疾保险金。In case the insured suffers from accidental disability during the insurance term, our company shall indemnify the accidental disability benefit according to the prevailing “Disability Level Compensation Rate” promulgated by our company. For those insured still under medical treatment, the disability level certified 180 days after the accident will be served as the criteria for the payment of “accidental disability benefit”.

被保险人因同一意外事故造成残疾程度与给付比例表所列残疾程度两项以上的,保险人给付各对应项意外残疾保险金之和。但不同残疾项目属于同一上肢或同一下肢时,仅给付一项意外残疾保险金;若残疾项目所属残疾程度不同时,给付较严重程度的残疾项目的意外残疾保险金。In case the insured is eligible for over two items of disability in the “Disability Level Compensation Rate” due to a single accident, our company shall indemnify the insurance benefit of all eligible items. Provided the different disability items belong to one hand or one foot, the insurance benefit for only one level of disability will apply. In case the disability items belong to different disability levels, the accidental disability insurance benefit of more serious disability will apply.

被保险人该次意外事故导致的残疾合并前次残疾可领较严重项目意外残疾保险金的,按较严重项目标准给付,但前次已给付的意外残疾保险金(投保前已有或因责任免除事项所致残疾程度与给付比例表所列残疾的,视为已给付意外残疾保险金)应予以扣除。In case the insured is eligible for the insurance benefit for more serious disability due to the current accident and the last disability, the insurance benefit for more serious disability will apply but shall be deducted by the last paid compensation of disability insurance benefit (for those suffering disability listed in the “Disability Level Compensation Rate” or suffering above disability arising out of the responsibility-exemption events, it shall be deemed as the disability insurance benefit already paid).

*每一被保险人的意外身故保险金及意外残疾保险金的累计给付金额以该被保险人的意外伤害保险金额为限,累计给付金额达到其意外伤害保险金额时,对该被保险人的保险责任终止。The accumulative indemnity of accidental death benefits and accidental disability benefits of each insured can not exceed the insurance sum; the insurance liability shall be terminated when the accumulative payment reaches to the insured sum of accidental insurance.

3.疾病身故保险金 disease death benefits

被保险人因疾病身故,保险人按其保险金额给付疾病身故保险金,对该被保险人的保险责任终止。In case the insured dies from disease, the insurer shall terminate the insurance liability upon indemnity of death benefits according to the insurance amount.

4.意外住院津贴 accidental in-patient allowance

被保险人在本保险有效期内因遭受意外事故并自事故发生之日起一百八十日内因该事故经医院确诊必须住院治疗的,保险人根据被保险人的合理住院天数,按100/天给付“意外住院医疗现金补贴”。

意外住院医疗现金补贴的累计给付日数最多为180日,累计给付日数达到180日时,对该被保险人的保险责任终止。

In case the insured suffers from accident and must receive in-patient treatment by the advice of hospital within 180 days from the day when the accident happens, insurer shall pay in-patient allowance benefits with RMB100 for each day according to the reasonable in-patient days with the limitation of 180 days, and insurer shall terminate insurance liability when payment days reach to 180.

5.意外医疗保险:accidental medical insurance

被保险人在本保险有效期间内,每次因遭受意外事故并在医院进行治疗,保险人就其事故发生之日起一百八十日内发生的、符合当地社会基本医疗保险规定的合理医疗费用按100%比例给付“意外医疗保险金”。During the insurance term, in case the insured catches accident and receives medical treatment within 180 days after the accident, insurer shall indemnify the reasonable medical expenses by 100% upon the reasonable medical expenses.

被保险人不论一次或多次遭受意外事故而造成合理医疗费用的,保险人均按上述约定分别给付意外医疗保险金,但累计给付金额以该被保险人的意外医疗保险金额为限,累计给付金额达到其意外医疗保险金额时,对该被保险人的保险责任终止。This benefit will be paid without reference to times of the accidents, but the accumulative total per capita shall not exceed the insurance sum. The insurance liability shall be terminated when the accumulative payment reaches to the insured sum.

6.住院医疗保险:In-patient medical insurance

在本保险有效期间内,尚未参加投保所在地社保的被保险人因遭受意外伤害保险事故或疾病,经医院确诊必须住院治疗的,保险人就其在住院期间发生的、符合当地社会基本医疗保险规定的0-40万元合理床位费、合理手术费与合理医疗费用(不包含个人全自费,包括乙类药品及基本医疗保险支付部分费用的诊疗项目中按比例由个人先自付部分费用),按照100%比例赔付“住院医疗保险金”。During the valid term of the contract, when the insured who has not joined in the social insurance suffers from accident or disease and must receive in-patient treatment upon the advice of hospital, insurer shall pay in-patient medical benefits by the rate of 100% upon the reasonable accommodation fee (0-400000), reasonable operation fee and reasonable medical expenses which are happened during in-patient term.

被保险人不论一次或多次住院治疗,保险人均在上述约定给付住院医疗保险金,累计给付金额达到其保险金额时,该项保险责任终止。Without reference to times of in-patient treatment, insurer shall pay supplementary in-patient medical benefits upon the mentioned appointment, the insurance liability shall be terminated when the accumulative payment reaches to the insured sum.

当保险期限结束时,被保险人必须继续接受住院治疗的,保险人继续承担保险责任90天,但累计给付金额达到保险金额时,保险责任终止。In case insured must continue to receive in-patient treatment when the insurance term ends, insurer shall undertake the insurance liability for 90 days, but the insurance liability shall be terminated when the accumulative payment reaches to insured sum.

7.交通意外身故保障:Traffic accidental death insurance

被保险人以乘客身份在乘坐所投保的客运公共交通工具期间因遭受意外事故,并自事故发生之日起180日内因该事故身故的,保险人按其意外伤害保险金额给付意外身故保险金,对被保险人保险责任终止。

In case the insured catches an accident and dies within 180 days after the accident when insured rides a public traffic vehicle as a passenger, insurer shall terminate the responsibility to the insured upon indemnity of the accidental death benefit.

8.交通意外残疾保障:Traffic accidental disability insurance

被保险人以乘客身份在乘坐所投保的客运公共交通工具期间因遭受意外事故,并自事故发生之日起180日内因该事故造成条款所附“残疾程度与给付比例表”所列残疾之一的,保险人按该表所列比例乘以其意外伤害保险金额给付意外残疾保险金。如治疗仍未结束的,按事故发生之日起第180日的身体情况进行残疾鉴定,并据此给付意外残疾保险金。In case the insured suffers from accidental disability when rides a public traffic vehicle as a passenger, insurer shall indemnify the accidental disability benefit according to the prevailing “Disability Level Compensation Rate” promulgated by insurer. If the insured is still under treatment, insurer shall pay the benefits upon the disability level appraisaled at the 180th day from the day when accident happens.

*被保险人的交通意外身故保险金及交通意外残疾保险金的累计给付金额以被保险人的交通意外伤害保险金额为限,累计给付金额达到交通意外伤害保险金额时,对被保险人该项保险责任终止。The accumulative total per capita of accidental death and accidental disability insurance benefit shall not exceed the insurance sum whether insured suffers from accident once or more.

二、责任免除exclusions

2.1 意外伤害保险、意外伤害医疗保险、意外住院现金补贴保险、疾病身故保险、交通意外保险、重大疾病保险的责任免除适用《平安团体意外伤害保险条款》、《平安附加意外伤害团体医疗保险条款》、《平安附加意外伤害住院现金补贴团体医疗保险条款》、《平安一年期团体定期寿险条款》、《平安交通团体意外伤害保险》、《平安团体重大疾病保险条款》的责任免除条款。The exclusions for Accidental insurance, Accidental medical insurance, Accidental in-patient allowance insurance, disease death insurance, traffic accidental insurance, dread disease insurance shall apply with the exclusions in Ping An Group Accidental Insurance Clause, Ping An Accessory Accidental Medical Insurance Clause, Ping An Accessory Accidental In-patient Allowance Medical Insurance Clause, Ping An One-year Term Life Insurance Clause, Ping An Traffic Accidental Insurance Clause, Ping An Group Dread Disease Insurance Clause.

2.2 医疗险因下列情形之一,导致被保险人医疗费用支出的,保险人不承担保险责任:The medical expenses caused under the following cases, the insurer shall not undertake the insurance liability:

1)投保人对被保险人的故意杀害、故意伤害;The applicant or beneficiary injures insured or makes the insured suffering from disease deliberately;

2)被保险人故意自伤、故意犯罪或者抗拒依法采取的刑事强制措施或自杀,但被保险人自杀时为无民事行为能力人的除外;the insured commits a crime or suicide, inflicts injury to himself/herself deliberately or resists the executed measurements carried out by low, but the case of committing a suicide happened to the person without civil activity ability shall be excluded;

3)被保险人殴斗、醉酒,主动吸食或注射毒品;The insured fights, indulgent of alcohol, takes, sucks or injects drug;

4)被保险人酒后驾驶、无合法有效驾驶证驾驶,或驾驶无有效行驶证的机动车;The insured drives under the influence of alcohol or drives without a valid driving license, or the vehicle dose not have a valid license;

5)被保险人感染艾滋病病毒或患艾滋病期间因疾病导致的;During the period when the insured has been diagnosed as an AIDS victim and/or AIDS virus carrier (HIV positive)

6)战争、军事冲突、暴乱或武装叛乱;War, military action, civil commotion, or armed rebellion;

7)核爆炸、核辐射或核污染;Nuclear explosion, nuclear radiation or nuclear pollution

8)遗传性疾病、先天性畸形、变形和染色体异常;The insured suffers from inherited disease, congenital abnormality, deformation or chromosome abnormality,

9)不孕不育治疗、性功能障碍、人工受精、怀孕、分娩(含难产)、流产、堕胎、节育(含绝育)、产前产后检查以及由以上原因引起的并发症(若有女性生育责任另有约定参照则以其为准);Diagnosis and treatment items for various infertilities and sexual dysfunction, artificial fertilization, pregnancy, parturition (including dystocia), abortion, misbirth, birth control (including sterilization), inspection before and after parturition and the caused syndrome (if the policy includes maternity liability, the policy shall be referred) ;

10)精神和行为障碍(依照世界卫生组织《疾病和有关健康问题的国际统计分类(ICD-10)》确定)、性病;Psychosis and activity obstruction(referring to international statistic classification about disease and health), social disease.

11)从事潜水、跳伞、攀岩、蹦极、驾驶滑翔机或滑翔伞、探险、摔跤、武术比赛、特技表演、赛马、赛车等高风险运动。The insured engages in sports or activities with high risks such as diving, parachuting, rock-climbing, expedition, martial arts, wrestling competitions, acrobatics, horse racing and automobile racing and any other high-risky sports;

12)被保险人在康复医院、联合诊所、民办医院、私人诊所、家庭病房、按摩医院、挂床等治疗;he insured receives treatment in the healing hospital, polyclinic, civil hospital, private clinic, domestic sickroom, massage hospital and sickbed hanging;

13)牙科保健:包括但不限于牙科护理、洗牙、牙移植、义齿、镶牙、牙体缺损修复、烤瓷牙、口腔修复、口腔正畸、口腔保健及美容;dental care: including but or limited to dental tending, dental washing, dental transplant, denture prostheses, dental implant, dental repair, artificial tooth mounting, prosthodontics and porcelain tooth baking and tooth cosmetics;

14)美容:包括但不限于皮肤色素沉着、面膜、疤痕美容、激光美容、脱痣、祛除纹身、除皱、祛雀斑、开双眼皮、治疗白发、治疗秃发、植发、脱毛、隆鼻、隆胸、穿耳洞项目;cosmetics: including but not limited to Various cosmetic and plastic treatments such as skin pigmentation, acne, facial maskscar removal, laser cosmesis,nevus removal, tattoo removal, wrinkle removal, freckle removal, Lid-folding operation, poliosis treatment, alopecia treatment, hair implant, epilation, augmentation rhinoplasty, mammoplasty, ear hole puncture;

15)矫形和视力矫正手术治疗:包括但不限于腋臭、口吃、鼻鼾手术(阻塞性睡眠呼吸暂停综合症除外)、平足、验眼配镜项目;Orthopedic treatments such as osmidrosis, halitosis, snoring surgery (expect respiratory distress syndrome) and flatfoot etc.;

16)减肥、增胖、增高、装配假眼、假肢或助听器项目;各种健康体检项目:包括但不限于体检、疾病普查项目;各种预防、保健性、疗养、静养或特别护理的诊疗项目:包括但不限于各种疫苗预防接种、足部反射推拿疗法、健身按摩项目;各种康复治疗项目;Body-building treatments such as losing weight, increasing weight and increasing height etc.; physical examinations such as health examination and disease screening etc.; preventive, healthy, recovering, resting or other special cares such as vaccinations, foot massage and physical massage;

17)被保险人所发生的当地社会基本医疗保险主管部门规定自费的医疗费用及其他不属于当地社会基本医疗保险范围内的医疗费用;Medical expense for self-paid items ruled by the regulation of the local social medical insurance;

18)非意外事故所致整容手术;各种医疗鉴定项目:包括但不限于劳动能力鉴定(职工劳动、工伤、职业病诊断鉴定),精神病人的司法鉴定,医疗事故鉴定,各种验伤费;Cosmetic operation which is not caused by accident; Various medical appraisal items such as labor capability appraisal (employee labor, industry injury, occupational disease appraisal), judicial appraisal for psychopath, malpractice appraisal, various inspection fee;

19)被保险人在中国境外、台湾、香港、澳门地区发生的医疗费用(条款另有约定的除外);the medical expenses caused out of china or in Taiwan, Hongkong and Macao (if the policy has the special agreements, it shall prevail)

20)检查、治疗、用药与所诊断疾病不符的;非本协议约定的急诊情况在急诊治疗的费用;代配药、外配药;无相关主述、疾病诊断的病史,直接配药或取药的;Expenses for examination, treatment and medicine which are not in compliance with the disease diagnosed; Medical expenses caused by the non-designated emergency cases in the agreement; Buy prescribe for others, prepare medicine outside the hospitals; Directly buying prescribe or buy medicine without case history of relevant patient statement and disease diagnosis;

21)索赔时未同时提供电脑打印的费用明细清单的或盖收费章注明药品价格处方的;Failure to provide computer-printed list for charge item or the prescription indicating medicine prices without charge seal when claiming;

2.3 被保险人因既往症引起的保险事故为本保险计划的责任免除。The exclusions to the insurance accident caused by the anamnesis (the disease caused before application).

三、未尽事宜以下列保险条款为准:The other events shall refer to the following clauses:

《平安团体意外伤害保险条款》(平保养发[2010]146)、《平安一年期团体定期寿险条款》(平保养发[2009]105号)、《平安交通团体意外伤害保险》(平保养发[2009]105号)、《平安附加意外伤害团体医疗保险条款》(平保养发[2010]123号)、《平安附加意外伤害住院现金补贴团体医疗保险条款》(平保养发[2009]105号)、《平安住院团体医疗保险条款》(平保养发[2010]123号)。Ping An group accidental death/disability insurance (No.146, P-B-Y-F [2010]), Ping An One-year term life insurance (No.105, P-B-Y-F [2009]), Ping An traffic group accidental death/disability insurance (No.105, P-B-Y-F [2009]),Ping An Accessory Accidental Medical Insurance(No.123, P-B-Y-F [2010]),Ping An accessory accidental in-patient allowance group medical insurance(No.105, P-B-Y-F [2009]), Ping An supplementary in-patient group medical insurance(No.123, P-B-Y-F [2010]). If the contents of the contract are different from the clauses, the clauses shall prevail.

 

另:中英文如有疑义,以中文为准。

If there is any difference between English version and Chinese version, the Chinese version shall prevail.