保险业务——保障内容
来源:    发布时间: 2017-11-29 03:47   317 次浏览   大小:  16px  14px  12px

在保险期间(从本次保险生效日期到截止日期的期限)内,本公司承担下列保险责任:
1、身故保险责任:
被保险人因意外事故或疾病身故,本公司按约定保险金额给付保险金,保险责任终止。
2、意外残疾保险责任:
被保险人因遭受意外事故,并自事故发生之日起180日内因该事故造成《人身保险伤残评定标准》所列伤残项目的,本公司依照该标准规定的评定原则对伤残项目进行评定,除另有约定外,本公司按评定结果所对应该标准规定的给付比例乘以相对应责任下的保险金额给付意外伤残保险金。如治疗仍未结束的,按事故发生之日起第180日的身体情况进行伤残鉴定,并据此给付意外伤残保险金。
被保险人该次意外事故导致的伤残合并前次伤残按照《人身保险伤残评定标准》可评定为较严重项目的,本公司按较严重项目标准给付,但前次已给付的意外伤残保险金(投保前已有或因责任免除事项导致《人身保险伤残评定标准》所列伤残的,视为已给付意外伤残保险金)应予以扣除。
每一被保险人的意外伤残保险金累计给付金额以该被保险人的保险金额为限,累计给付金额达到其保险金额时,对该被保险人的保险责任终止。
注:《人身保险伤残评定标准》可登陆中国保险行业协会网站查看。
每一被保险人的意外残疾、意外身故、疾病身故保险金的累计给付金额以其对应的保险金额为限。
3、意外伤害医疗保险责任:
被保险人因遭受意外事故,并自事故发生之日起一百八十日内进行治疗,保险人就其实际支出的合理且必要的医疗费用按100%给付意外伤害医疗保险金,累计给付金额以20,000元为限。被保险人不论一次或多次发生意外伤害保险事故,保险人均按上述规定分别给付“意外伤害医疗保险金”,但累计给付金额以不超过该被保险人的保险金额为限,累计给付金额达到其保险金额时,对该被保险人的该项保
险责任终止。
4、门急诊医疗保险责任:
被保险人因疾病在门诊进行治疗所发生的合理且必要的医疗费用,在一个保险期间内,就诊日费用限额为600元(即:若当日医疗费用超日限额的只能按600元计算,当日医疗费用未超600元限额的按实际发生金额计算),在日限额的基础上累计达到2000元(起付线)以上的部分保险人按照85%的比例予以赔付,累计给付保险金额以20000元为限。当累计给付金额达到其保险金额时,对被保险人的该项保险责任终止。
门急诊医疗保险责任包括:普通门诊、急诊、门诊手术、急诊留观、急诊抢救所产生的相关费用;由公立医院或卫生防疫部门提供证明的传染病因隔离期间所产生的相关费用;因与住院同一病因而产生的院前、院后的门诊费用等均归属于门急诊医疗责任范围内。
释:
日限额:为每日就诊的最高费用限额。
起付线:本险种设置2000元为起付线(一个保险期间内累计一次),起付线以下部分不予赔付。
5、住院医疗保险责任:
被保险人因遭受意外事故或疾病,经医院诊断必须住院治疗的,本公司就其实际支出的合理且必要的护工费(限额100元/天,最多累计30天)、建病历费、取暖费、空调费、床位费、检查检验费、特殊检查治疗费、手术费、药费、治疗费、化验费、放射费等合理医疗费用,按100%的比例向被保险人给付“住院医疗保险金”。
在一个保期内,被保险人不论一次或多次住院治疗,本公司均根据理赔规则向其给付保险金,每次给付的住院医疗保险金累计相加达到400,000元时,该项保险责任终止。
注:
1)以上所有医疗保险责任所涉及的医疗机构仅限于在中华人民共和国大陆境内的公立医院。但是,若被保险人是在公立医院的分院、外宾病区、VIP病区、包房、单间、特诊特需病区、特诊特需病房和高干病房等同类病区或病房接受的治疗,则其所有的医疗费用本公司均不予报销。
2)以上所有医疗保险责任所涉及的医疗费用只限于当地社会基本医疗保险可报销项目内的费用,自费和部分自费项目本公司均不予报销。
3)首次投保或非连续投保的被保险人,自投保之日起30日内为等待期(观察期),如等待期内发生住院或疾病门诊的医疗费用,本公司不承担理赔责任。连续投保或被保险人遭受意外事故进行治疗的无等待期。
4)以上所有医疗费用,若其它第三方支付了部分或全部费用,我司仅就剩余的、且在当地社会基本医疗保险可报销项目范围内的合理费用予以赔付;但保险责任中所涉及的床位费、护工费、门急诊日限额等限额部分同样受限,如第三方有赔付比例的受限部分按照受限金额为基础扣除已赔付金额,我司只赔付剩余金额,如无赔付比例,受限部分按照当地社会医疗保险的标准, 以受限金额为基础扣除此项目的标准金额,赔付剩余金额,并以保险金额为限。
5)被保险人在本次投保前发生重大疾病或慢性病的,保险人不承担给付保险金的责任。

 

Insurance coverage:
Ping An shall undertake the following insurance liabilities during the valid period of insurance (Insurance period (from the valid date of policy to the expiry date of the insurance period))
1、 Death insurance:
Ping An shall pay the stipulated amount of insurance compensation if the Insured dies of any accident or disease. Insurance liabilities thus terminate.
2、 Accidental disability insurance:
If the Insured suffers from any accident which results in any disability listed in the Injury and Disability Assessment Criteria for Personal Insurances within 180 days since the occurrence of the accident, according to the policy Ping An shall pay the insurance money, whose amount shall be calculated based on the multiplication of the sum insured, which is corresponding to insurer’s responsibilities, and the proportion that is specified in the “Proportion Table of Disability Degree and Payment” of Ping An Annuity Insurance Company, Ltd. If medical treatment is still not over on the 180th day, disability evaluation shall be made on the basis of the Insured’s physical condition on that day and the “Insurance of Accidental Disability” shall be paid in accordance with the “Proportion Table of Disability Degree and Payment”.
If the same accident causes the Insured to suffer two or more disabilities, as are specified in the “Proportion Table of Disability Degree and Payment”, the Insurer (PingAn) shall pay the total insured amount of the relevant disabilities. However, if different disabilities befall the same upper limb or lower limb, only the insured amount of one disability shall be paid; if disabilities are of different degrees, the insured amount of the disability that is more serious shall be paid.
If, with the disability resulted from this accident and the previous disability combined, the Insured can claim the insurance for the more serious disability, the insurance shall be paid in accordance with the standard for the more serious disability, but the disability insurance which has been paid previously (disabilities that
have taken place before purchase of insurance, or disabilities that are caused by and as a result of liability exemption and are listed in the “Proportion Table of Disability Degree and Payment” shall be deemed as having been compensated already) shall be deducted therefrom.
Note: “Proportion Table of Disability Degree and Payment” is accessible from the website of INSURANCE ASSOCIATON OF CHINA.
The accumulative amount of payment of insurance for death or accident of each insured shall not exceed the insured sum of the insured’s total insurance for the death or accident.
3、 Medical Insurance for Accidental Injury:
If the Insured receives medical treatment within 180 days since the occurrence of the accident, the Insurer shall be liable for the payment of the full amount of the reasonable and necessary expenses actually paid by the Insured for the medical treatment, but the accumulative amount of payment shall not exceed the agreed sum insured, which is up to RMB 20,000 limitation. Whether an accidental injury happens to the Insured for once or several times, the Insurer shall pay the respective “medical insurance for accidental injury” in accordance with the foresaid provisions, but the accumulative amount of payment shall not exceed the Insured’s sum insured. When the accumulative amount of payment reaches the Insured’s sum insured, the said insurance liability for the said Insured shall be terminated.
4、 Outpatient and Emergency Medical Insurance:
If the Insured receive outpatient or emergency medical treatment because of illness and actually incur reasonable and necessary expenses for medical treatment, Within the insurance time , the daily limit for outpatients is RMB600. On the precondition of not exceeding the daily limit, should the daily medical cost is less than RMB600, the actual cost shall be used for calculation. if the daily medical expenses and cost is more than RMB600, the Insurer only cover RMB600 per day.For medical expenses exceeding the starting line of RMB2000, their remaining amount after deducting RMB2000 will be reimbursed at a percentage of 85%, and the accumulative payment shall not exceed the limit of RMB20000. The insurance liability shall be terminated once the accumulative amount of payment reaches the sum insured.
Insurance Responsibilities of emergency medical treatment and general outpatient treatment include: The fees of general outpatient treatment, emergency treatment, outpatient surgery, hospitalization for observation, emergency rescue, isolation due to infectious diseases that is certified by the public hospital or department of public health and epidemic prevention, and expense or cost of outpatient and emergency treatment before and after hospitalization that arise from the same cause of disease are also deemed as outpatient and emergency treatment.
Note:
Daily limit: The top claim limit of available medical cost
Starting-line to pay the limitation: RMB 2000 (accumulative for one time during one valid insurance period). Below the starting-line, there is no claim.
5、 Hospitalization and Medical Insurance:
If diagnosis confirms that the Insured must be hospitalized for treatment because of suffering from the accident or the illness Ping An shall be liable for the full payment of the “hospitalization and medical insurance” with regard to the actual and reasonable expenses for medical treatment, including reasonable and necessary fees for nursing (limited to RMB100 Yuan per day for limitation of accumulative 30 days), medical record, heating, air-conditioning, bed, examination, special examination and treatment, operation, medicine, treatment, laboratory test, radiation, etc to the insured as 100% proportion.
During one valid insurance period, whether the Insured is hospitalized for once or several times, the Insurer shall pay the costs of hospitalization as per compensation rule, but the insurance liability shall be terminated once the accumulative amount of payment reaches the limitation of RMB 400,000.
Note:
1) Medical organizations which are involved in all the foregoing medical insurance liabilities are limited to the public hospitals established within the border of the Chinese mainland; However, for the insured, all medical expenses incurred in sub-branch of public hospitals, ward area for foreigners, ward area for special treatment and needs, ward for special treatment and needs, ward for high-ranking officials, or similar ward area or VIP ward room or separate ward room, shall be excluded from the insurance, and such expenses for treatment shall not be covered by the insurer.
2) Medical treatment expenses generated by all the foregoing medical insurance liabilities are limited to the items and expenses that can be reimbursed in accordance with the local regulations of social basic medical insurance, the self-paid or partly self-paid items and expenses cannot be reimbursed by the insurer.
3) The first 30 days period of the first application for insurance or non-continuous coverage is waiting period (observation period). Where the insured is hospitalized or outpatient during the waiting period and related medical cost is occurred, the insurer bears no liability of compensation. The treatment for continuous insured or the Insured suffered from an accident is not subject to any waiting period.
4) If any third party has partially or fully paid any above-mentioned medical treatment fees, Ping An shall be liable for the amount of reasonable fees that are in accordance with the payment scope. But the fees for nursing, bed, outpatient and emergence treatment daily limitation fee and other fees within the insurance coverage are also limited. If the third party has a specified proportion for payment, then Ping An shall be liable only for the payment within its proportion deducting the already paid amount. If the third party has no specified proportion for payment, then Ping An shall be liable for the rest, not exceeding the insured sum, of the limited amount in accordance with the regulations of the local social medical insurance and with a deduction of the standard amount of this item.
5) If the Insured suffers from a major disease or a chronic disease before the purchase of this insurance, the Insurer shall not bear the liability of payment.

 

Power by 建站之星 | 美橙互联 版权所有