BASIC DEFINITIONS
DEFINITIONSIn this Policy:
“Active Treatment” means any therapeutic intervention with the aim of prolonging the Insured’s life, including but not
limited to radiotherapy, chemotherapy, targeted therapy, hormonal therapy, immunotherapy, proton therapy and surgery for a Covered Cancer, including any complications thereof (if applicable). It does not include any treatment given solely as Palliative Treatment.
“Anaesthetist” means an Independent Person (other than the Registered Medical Practitioner operating on the Insured)
legally authorized by the government of the geographical area of his practice to perform anesthesiology services.
“Basic Policy” means this Policy (as may be amended by endorsement from time to time) excluding coverage issued under
any Supplementary Contract.
“Beneficiary” means the person or persons designated in the application form as the beneficiary under this Policy (as may be
amended from time to time in accordance with this Policy).
“Cancer” means:
Any cancer positively Diagnosed with histological confirmation or preparations from the haemic system (including but not limited to, peripheral blood smears and bone marrow examination), and characterized by the uncontrolled growth of malignant cells and invasion of tissue.
For the purpose of this contract, the term Cancer will include: (1) all stages of malignant cancer, and
(2) Carcinoma-in-situ,
but will specifically exclude the following:
(a) any tumour which is histologically classified as pre-malignant;
(b) abnormal lesions of cervix uteri classified as cervical intra-epithelial neoplasia grade I (CIN I) and grade II (CIN II); and (c) any cancer where HIV Infection is also present.
“Carcinoma-in-situ”, which means a histologically proven, localized pre-invasion lesion where cancer cells have not yet
penetrated the basement membrane or invaded (in the sense of infiltrating and / or actively destroying) the surrounding tissues or stroma.
“Commencement Date” (a) in relation to an amendment of the Policy or a Supplementary Contract issued after the Basic
Policy, means the date shown on the relevant endorsement as the Commencement Date; and (b) in relation to a reinstatement of the Policy, means the date on which the Policy is reinstated in accordance with the terms of this Policy.
“Company”, “we”, “us” or “our” refers to AIA International Limited.
“Confinement” or “Confined” means admission of the Insured to a Hospital as an In-Patient following the later of the Issue
Date and the latest Commencement Date upon the recommendation of a Registered Medical Practitioner for a Continuous Physical Stay for Medically Necessary treatment in the Hospital prior to the Insured’s discharge, provided that the duration of such Stay is six (6) hours or more. For the avoidance of doubt, and notwithstanding any other provisions of this Policy, an admission to Hospital will not be, or will cease to be, regarded by the Company as a Confinement for purposes of this Policy where the ensuing stay on Hospital is not a Continuous Physical Stay as defined.
“Contingent Owner” means the person named by the Owner as “Contingent Owner” in the Company’s prescribed form,
who may become the Owner pursuant to the “Change of Ownership” provisions under the OWNERSHIP PROVISIONS of the Policy. It is only applicable for Policy with Insured under 18 years old when the Policy is issued.
“Continuous Physical Stay” or “Stay” means the continuous physical presence of the Insured as an In-Patient on the
Hospital premises, without any physical absence or interruption throughout the period commencing from the Insured’s admission to a Hospital until his full and formal Discharge therefrom.
“Covered Cancer” means Cancer occurring more than 90 days after the later of the Issue Date and the latest Commencement
Date of this Policy. For this purpose, a Cancer is regarded as having occurred when it has been investigated, diagnosed or treated or when its signs or symptoms have manifested which will cause an ordinary prudent person to seek diagnosis, care or treatment. In the event of any conflict or discrepancy of opinions relating to the signs or symptoms of a Cancer and their manifestation between a Registered Medical Practitioner or Surgeon and the Insured, we will adopt and follow the Registered Medical Practitioner or Surgeon’s professional opinion.
“Covered Cancer Limit” as shown on the Schedule of Benefits, means the maximum aggregate amount paid or payable in
respect of the benefits under Parts I-IV of the BENEFIT PROVISIONS for any and all Covered Cancer suffered by the Insured for every three (3) consecutive years during the Term, provided that Covered Cancer Limit shall be deemed to be zero upon the total aggregate amount paid under Parts I-IV of the BENEFIT PROVISIONS during the lifetime of the Insured reaching the Lifetime Cancer Limit.
“Designated Plans” means the following insurance policies covering the Insured and issued by us:
(a) Plus Plan of Cancer Guardian 2 series; (b) Mega Plan of Cancer Guardian 2 series; (c) Plus Plan of Cancer Guardian Pearl 2 series; and (d) Mega Plan of Cancer Guardian Pearl 2 series.
“Diagnosis” or “Diagnosed” means the definitive diagnosis made by a Registered Medical Practitioner as defined below,
based upon specific condition(s) referred to in the definition of the condition, illness or disease concerned or, in the absence of such specific condition(s), based upon radiological, clinical, histological or laboratory evidence of the relevant condition, illness or disease acceptable to the Company. Such Diagnosis must be supported by the Company’s Medical Director who may base his opinion on the medical evidence submitted by the Insured and / or Owner and / or any additional evidence he may require.
In the event of any dispute or disagreement regarding the appropriateness or correctness of the Diagnosis, the Company shall have the right to call for an examination, of either the Insured or the evidence used in arriving at such Diagnosis, by an independent Registered Medical Practitioner with expertise in the field of medicine concerned selected by the Company and the opinion of such expert as to such Diagnosis shall be binding on both the Insured and the Company.
“Diagnostic Test” shall mean any test or investigation modality which is Medically Necessary to positively Diagnose a
Covered Cancer, including but not limited to laboratory tests, X-rays, computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), fine needle aspiration for cytology or histopathology, or excisional biopsy for histopathology. Genetic testing to aid the identification of appropriate chemotherapy drugs is also included.
“Discharge” means the departure of the Insured from the Hospital (whether to return home or for transfer to another
Hospital or facility), following finalization of all formal procedures within the Hospital to end the Confinement and billing of outstanding charges for full settlement, with no room or bed retained for the Insured at the Hospital.
“Grace Period” has the meaning ascribed to such term under the PREMIUM PROVISIONS.
“HIV Infection” shall be deemed to have occurred where blood or other relevant test(s) indicate, in the opinion of the
Company, either the presence of any Human Immunodeficiency Virus, antigens or antibodies to such a virus.
“Hospital” means a lawfully operated institution licensed as a hospital for the care and treatment of injured or ill persons
which provides facilities for diagnosis, major surgery and 24-hour nursing service and is not primarily a rest or convalescent home, or similar establishment or, other than incidentally, a place for alcoholics or drug addicts.
“Immediate Family Member” means the legally married spouse or a child or parent of the Insured or the Owner (as the
case may be).
“Independent Person” means a person other than (a) you or the Insured; (b) an Immediate Family Member of yours or the
Insured; (c) a business partner of yours or the Insured; (d) the employer or employee of either yourself or the Insured; (e) an insurance agent of the Company; or (f) an insurance representative of yours or the Insured.
“In-Patient” means the Confinement of the Insured for a Covered Cancer as a registered resident bed patient where the
Insured uses and is charged for room and board facilities of the Hospital.
“Insured” means the person as shown on the Policy Information Page as the “Insured”.
“Intensive Care Unit” (ICU) means a section within a Hospital which is designated as an intensive care unit by the
Hospital providing one to one nursing care, in which patients undergo specialized resuscitation, monitoring and treatment procedures. The unit must be staffed 24 hours a day with highly trained nurses, technicians and doctors, and be equipped with resuscitative equipment and monitoring devices that allow continuous assessment of vital body functions such as heart rate, blood pressure and blood chemistry.
“Issue Date” means the date shown on the Policy Information Page as the “Issue Date” and the date on which the Policy
came into force.
“Issuing Office” means: 1) where this Policy is issued in Hong Kong, AIA International Limited in Hong Kong at the address
shown on the Policy Information Page; 2) where this Policy is issued in Macau, AIA International Limited in Macau at the address shown on the Policy Information Page; or 3) such other address (if any) as we may notify you in writing from time to time.
“Licensed or Graduate Nurse” means an Independent Person who, upon successful completion of a course at a recognized
college or school of nursing, is legally authorized by the government of the geographical area of his practice to render nursing services.
“Lifetime Cancer Limit” as shown on the Schedule of Benefits, means the maximum aggregate amount paid or payable
during the lifetime of the Insured in respect of the benefits under Parts I-IV of the BENEFIT PROVISIONS.
For the avoidance of doubt, only benefits paid or payable under Parts I-IV of the BENEFIT PROVISIONS up to the Covered Cancer Limit are included in the Lifetime Cancer Limit, and any amounts paid or payable under Parts I-IV of the BENEFIT PROVISIONS in excess of the Covered Cancer Limit up to the limit of Target Protection Benefit pursuant to Part V of the BENEFIT PROVISIONS are excluded from the Lifetime Cancer Limit.
“Medically Necessary” is a medical service, procedure or supply, which in the Company's opinion:
(a) is consistent with generally accepted professional standards of medical practice; (b) is required to establish a Diagnosis and/or to provide treatment; and
(c) cannot be safely delivered at a lower level of medical care.
Experimental, screening and preventive services or supplies are not considered Medically Necessary.
“Out-Patient” means an Insured who receives services and supplies in connection with treatment for Covered Cancer
given in the clinic of a Registered Medical Practitioner, a Registered Chinese Medicine Practitioner, a day surgery centre, or in the out-patient department, emergency treatment room or day surgery centre of a Hospital.
“Owner”, “you” or “your” is the person who owns this Policy and shown on the Policy Information Page as the “Owner”,
subject to the “Change of Ownership” provisions under the OWNERSHIP PROVISIONS of this Policy, if applicable.
“Palliative Treatment” means treatment intended only to improve the quality of the Insured’s life in the case of a life
threatening Covered Cancer by relieving pain or alleviating other symptoms of the Covered Cancer and/or complication(s) thereof, or the side effects of its/their treatment, without any attempt at its/their cure.
“Policy” consists of:
(a) Basic Policy (including schedules); (b) Policy Information Page;
(c) application for the Basic Policy and for Supplementary Contracts (if any), including the application forms (if any), any subsequent amendments, declarations and statement duly made by the Owner and/or the Insured;
(d) endorsements to this Policy (if any); and (e) Supplementary Contacts (if any).
“Policy Anniversary” refers to the same date in each subsequent year as the Policy Date. If the Policy Date is 29 February of
a leap year, then the Policy Anniversary will be 28 February in a non-leap year.
“Policy Date” means the date shown on the Policy Information Page as “Policy Date” and the date from which Policy Years,
policy months, Policy Anniversaries and Premium Due Dates are determined.
“Policy Debt” means the aggregate amounts that you owe us under this Policy, including any accrued interest. “Policy Information Page” means the schedule to the Basic Policy headed “Policy Information Page”.
“Policy Year” means each twelve-month period starting on the Policy Date.
“Pre-existing Condition” means (1) any physical, medical or mental condition or (2) any illness or disease:
(a) that existed;
(b) that was investigated, Diagnosed, or treated by a Registered Medical Practitioner; (c) for which a Registered Medical Practitioner was consulted; or
(d) the signs or symptoms of which commenced,
before the later of the Issue Date and the latest Commencement Date.
“Premium Due Date” refers to the date when the premium payment is due and payable under this Policy and as described on
the Policy Information Page or as stated on our written notification as may be amended from time to time.
“Psychological Counselling” means counselling or consultation with a Registered Psychiatrist / Registered Clinical
Psychologist for the psychiatric management of a mental, behavioural, psychiatric or psychological disorder but not limited to anxiety, anorexia, depression, stress, fatigue, or psychiatric complications of physical disorders, cognitive impairment and sleep disorders.
“Reasonable and Customary” in relation to a fee, a charge or an expense, means any fee or expense which (a) is charged
for treatment, supplies (inclusive of medication) or medical services that are Medically Necessary and in accordance with standards of good medical practice for the care or treatment of an ill person under the care, supervision or order of a Registered Medical Practitioner; (b) does not exceed the usual level of charges for similar treatment, supplies (inclusive of medication) or medical services in the locality where the expense is incurred, which for the avoidance of doubt, shall not exceed the level of such charges applicable to a Semi-Private Room for treatment, supplies (inclusive of medication) or medical services provided during a covered Confinement; and (c) does not include charges that would not have been made if no insurance existed. The Company reserves the right to determine whether any particular Hospital/medical charge is a Reasonable and Customary charge with reference but not limited to any relevant publication or information made available, such as schedule of fees, by the government, relevant authorities and recognized medical association in the locality. The Company reserves the right to adjust any and all benefits payable in relation to any Hospital/medical charges which in the opinion of the Company’s Medical Director is not a Reasonable and Customary charge.
“Reasonable and Customary Hospital Confinement” in relation to a Confinement, means a Confinement in Hospital for
a Covered Cancer which is Medically Necessary, where the admission of the Insured, length of Confinement, and medical services and treatment received during Confinement: (a) are all in accordance with standards of good medical practice; and (b) do not exceed the usual standard for the treatment of such Covered Cancer at the location where such Confinement takes place. For the avoidance of doubt, a Confinement is not a Reasonable and Customary Hospital Confinement if it is in respect of a medical procedure or treatment which, having regard to standards of good medical practice: i) is routinely performed on other patients on an Out-Patient basis; and ii) could reasonably have been performed on the Insured as an Out-Patient.
“Reconstructive Surgery” means the actual undergoing of plastic or reconstructive surgery on the head or on the breast
which is deemed to be Medically Necessary to restore function or appearance following previous surgery on the head or breast done for treatment of a Covered Cancer. Surgery solely for isolated dental restorations is excluded.
“Registered Chinese Medicine Practitioner” means an Independent Person who is an herbalist or an acupuncturist
registered with the Chinese Medicine Council of Hong Kong according to the Chinese Medicine Ordinance or with the local medical authorities at the place of treatment if such treatment is received outside Hong Kong.
“Registered Dietician” means an Independent Person who is legally authorized in the geographical area of his practice to
render dietician consultation services.
“Registered Medical Practitioner” or “Surgeon” means an Independent Person qualified by degree in western medicine
who is licensed to practice western medicine and legally authorized in the geographical area of his practice to render medical or surgical services.
“Registered Physiotherapist” means an Independent Person who is qualified and legally authorized in the geographical area of his practice to render assessment and treatment service on physical disability by means of cryotherapy, heat therapy, electrotherapy, manual therapy, traction, exercise therapy, hydrotherapy and acupuncture.
“Registered Psychiatrist” or “Registered Clinical Psychologist” means an Independent Person who is qualified by degree
in psychiatry or psychology (respectively) and is legally authorized in the geographical area of his practice to render psychiatric or psychological services, respectively.
“Schedule of Benefits” means the Schedule of Benefits appended to this Policy.
“Semi-Private Room” means a single or double occupancy room, with a shared bath/shower room, in a Hospital.
“Special Terms” means the special terms you have agreed for your Policy, if any, (including, but not limited to, special terms
to reflect increased risks in relation to residence, nationality or health).
“Supplementary Contract” means the terms and conditions set out in any supplementary contract or rider to the Basic
Policy in relation to benefits supplemental to your Basic Policy benefits.
“Term” means a period starting on the date of first Diagnosis of the first Covered Cancer suffered by the Insured and ending
on the date when the total aggregate amount paid under Parts I-IV of the BENEFIT PROVISIONS during the lifetime of the Insured reaches the Lifetime Cancer Limit.
GENERAL INTERPRETATION AND APPLICATION
Where the context requires, words importing one gender shall include the other gender, and singular terms shall include the plural and vice versa.
Headings are for convenience only and shall not affect the interpretation of this Policy. References to sections, clauses, provisions and schedules are to sections, clauses, provisions and schedules to this Policy.
Schedules to this Policy form part of this Policy.
BENEFIT PROVISIONS
While this Policy is in force and during the Insured’s lifetime, following Diagnosis of a Covered Cancer or any complication of Covered Cancer suffered by the Insured, we will reimburse the Reasonable and Customary charges for actual charges incurred pursuant to Parts I-VI herein (except Part VI.1, VI.2, VI.3 and VI.4), or pay the benefit(s) under Part VI.1, VI.2, VI.3, VI.4 and/or Part VII, subject to the following:
i) the terms and conditions of the Policy (including but not limited to the “Limitations of Benefits” and “Limitations of Confinement Benefits” sections);
ii) the Covered Cancer Limit for the benefits under Parts I-IV herein; iii) the Lifetime Cancer Limit for the benefits under Parts I-IV herein;
iv) the maximum limits shown in the Schedule of Benefits for the benefits under Part V (Target Protection Benefit) and Part VI (Additional Caring Benefits ) herein; and
v) the benefits under Part II.1(f), Part V (Target Protection Benefit) and Part VI.4 herein are only available for Designated Plans.
For purposes of applying the Covered Cancer Limit, there shall only be one and the same Covered Cancer Limit for all Covered Cancers suffered by the Insured for every three (3) consecutive years during the Term.
Once the aggregate amount paid or payable in respect of benefits under Parts I-IV herein reaches the Lifetime Cancer Limit as shown on the Schedule of Benefits, coverage under the BENEFIT PROVISIONS will automatically cease and this Policy shall terminate.
PART I DIAGNOSTIC BENEFIT
(a) Subject to the Covered Cancer Limit and Lifetime Cancer Limit, we shall reimburse the Reasonable and Customary charges actually incurred for any Medically Necessary Diagnostic Test(s) which directly confirms the positive Diagnosis of Covered Cancer undergone by the Insured in a Hospital or a clinic under the supervision of a Registered Medical Practitioner.
For the avoidance of doubt, any charges incurred in respect of routine health screenings which are not for the specific purpose of identifying the existence, nature or extent of a Covered Cancer shall not be covered, regardless of the results of the related tests/procedures.
(b) If the Insured is Confined in Hospital for performance of a Diagnostic Test and such Confinement is Medically Necessary for performing the Diagnostic Test, we shall also reimburse the Reasonable and Customary charges actually incurred for such Confinement (based on the level of such charges applicable to Confinement in a Semi-Private Room) pursuant to Part II.1 (Hospitalisation And Treatment Benefits).
PART II CANCER TREATMENT BENEFITS
Subject to the Covered Cancer Limit and Lifetime Cancer Limit, we shall reimburse the Reasonable and Customary charges actually incurred for consultation and/or treatment for the Insured, either on an In-patient or Out-patient basis, for Active Treatment or Palliative Treatment of a Covered Cancer and/or any complication(s) thereof, including the following:
1. Hospitalisation And Treatment Benefits
If the Insured is Confined in Hospital for Active Treatment or Palliative Treatment of a Covered Cancer, we shall reimburse the Reasonable and Customary charges actually incurred (based on the level of such charges applicable to Confinement in a Semi-Private Room) for:
a. hospital daily room and board during the Insured’s Confinement;
b. any visits made by the Insured’s attending Registered Medical Practitioner to the Insured at his Hospital bed during his Confinement;
c. Intensive Care Unit (ICU) charges made by the Hospital; *** End of Page ***
d. Surgical expenses, including:
the Surgeon’s fees;
the Anaesthetist’s fees; and
charges for use of the operating theatre (including the items and equipment used in the operating theatre); e. Miscellaneous hospital expenses, including:
Drugs and medicines prescribed by the Insured’s attending Registered Medical Practitioner and consumed in the Hospital;
Dressing, ordinary splints and plaster casts but excluding special braces, artificial limbs, appliances and equipment;
Laboratory examinations;
Electrocardiograms;
Basal Metabolism Tests;
Physiotherapy;
X-ray examinations;
Intravenous injections and solutions;
Administration of blood and blood plasma but excluding costs of blood or blood plasma; and
Ambulance service to or from the Hospital of Confinement; and
f. Hospital Companion Bed, including one (1) extra bed for one (1) person who accompanies the Insured in the Hospital. This benefit is only available for Designated Plans.
2. Day Treatment and Surgery
a. We shall reimburse the Reasonable and Customary charges for consultation and treatment actually incurred for Active Treatment or Palliative Treatment of the Insured by a Registered Medical Practitioner on an Out-patient basis, including but not limited to radiotherapy, chemotherapy, targeted therapy, hormonal therapy, immunotherapy, proton therapy and day surgery. For the avoidance of doubt, the covered Reasonable and Customary charges actually incurred for radiotherapy include the consultation fee for the planning session and consumables specified for the purpose of radiotherapy.
b. We shall also reimburse the Reasonable and Customary charges actually incurred for medication prescribed by the Insured’s attending Registered Medical Practitioner for Active Treatment or Palliative Treatment of the Insured, including anti-nausea drugs, anti-rejection drugs, anti-vertigo drugs and anti-anodyne. Long-term medication for Active Treatment or Palliative Treatment of the Insured, including but not limited to hormonal therapy prescribed by the Insured’s attending Registered Medical Practitioner subsequent to surgery for Active Treatment or Palliative Treatment of the Insured, is also covered.
PART III RECONSTRUCTIVE SURGERY BENEFIT
Subject to the Covered Cancer Limit and Lifetime Cancer Limit, we shall reimburse the Reasonable and Customary charges actually incurred for Reconstructive Surgery performed on the Insured which is recommended in writing by the Insured’s attending Registered Medical Practitioner, including the Reasonable and Customary charges actually incurred for:
a. the Surgeon’s fees; b. the Anaesthetist’s fees;
c. charges for use of the operating theatre (including the items and equipment used in the operating theatre); and d. the cost of any implants.
If the Insured’s Confinement in the Hospital is Medically Necessary for such Reconstructive Surgery, subject to the Covered Cancer Limit and Lifetime Cancer Limit, we shall also reimburse the Reasonable and Customary charges actually incurred for such Confinement (based on the level of such charges applicable to Confinement in a Semi-Private Room) pursuant to Part II.1 (Hospitalisation And Treatment Benefit).
PART IV MONITORING BENEFIT
Subject to the Covered Cancer Limit and Lifetime Cancer Limit, in addition to any Diagnostic Tests to directly confirm a positive Diagnosis of Covered Cancer covered under Part I.(a) herein, for up to five (5) years from the date of completion of Active Treatment on the Insured, we shall reimburse the Reasonable and Customary charges actually incurred in respect of the consultation fee as well as laboratory tests, imaging procedures or screening tests undertaken to monitor the Insured’s response to treatment and progress of the Insured’s recovery after completion of treatment and/or consultation(s) covered under Part II herein.
If the Insured’s Confinement in Hospital is Medically Necessary for such monitoring, subject to the Covered Cancer Limit and Lifetime Cancer Limit, we shall also reimburse the Reasonable and Customary charges actually incurred for such Confinement (based on the level of such charges applicable to Confinement in a Semi-Private Room) pursuant to Part II.1 (Hospitalisation and Treatment Benefits).
Any routine health screening carried out which is not directly due to the Covered Cancer shall not be covered.
For the avoidance of doubt, this Benefit only covers eligible charges incurred following completion of Confinement, Active Treatment or Palliative Treatment of the Insured covered under Part II herein. Any charges incurred for Confinement, treatment, consultation and/or medication for a Covered Cancer or any complication(s) thereof are not covered hereunder but shall be covered only in accordance with the provisions of Part II herein.
PART V TARGET PROTECTION BENEFIT
This benefit is only available for Designated Plans.
Subject to the “Termination” provisions under the GENERAL PROVISIONS and other applicable terms and conditions of the Policy, if the Insured is diagnosed with any of the following Covered Cancers:
(a) any Covered Cancer which has been classified as Stage IV malignant tumour pursuant to the American Joint Committee on Cancer (AJCC) staging system;
(b) Liver Cancer; (c) Brain Cancer; (d) Blood Cancer; and (e) Lymphoma,
there shall be an additional benefit amount equals to 50% of the Covered Cancer Limit for (1) total benefits which may be claimed under Parts I-IV herein and (2) such Covered Cancers specifically mentioned in this Part V, provided that this benefit shall only be utilised one time only while this Policy is in force.
PART VI ADDITIONAL CARING BENEFITS
1. 1-Year Waiver of Premium
Upon the first Diagnosis of first Covered Cancer (excluding Carcinoma-in-situ for the purpose of this section) suffered by the Insured, we shall waive the premiums payable under this Policy for one (1) year. The first premium to be waived shall be the one falling due immediately after the date following the first Diagnosis of first Covered Cancer (excluding Carcinoma-in-situ for the purpose of this section) suffered by the Insured, except any premium falling due shall continue to be paid pending our approval of a claim hereunder. Following such approval, we shall refund any premiums (without interest) paid which are later waived hereunder.
Regardless of the mode of payment of premiums selected under the Policy, any waiver of premiums hereunder shall be effected as if the Policy were on a monthly premium mode. However, there shall be no waiver of any premium the due date of which is more than one (1) year before the day of receipt by us of written notice of claim for waiver of premiums hereunder.
2. Daily Hospital Cash Benefit for ICU
For any Confinement which is covered under Part II.1 (Hospitalisation and Treatment Benefit), we shall pay a daily Hospital Cash benefit in the amount shown on the Schedule of Benefits for each day of Confinement of the Insured in the Intensive Care Unit (ICU). This benefit is restricted to one payment of Hospital Cash benefit for each day of Confinement in the ICU, and is subject to the maximum number of days per Policy specified in the Schedule of Benefits.
3. Daily Hospital Cash Benefit for Long Term Hospitalisation
We shall pay a Daily Hospital Cash Benefit in the amount shown on the Schedule of Benefits for each day of Confinement of the Insured for a Covered Cancer commencing from the thirty-first (31st) day of a covered Confinement after a Continuous Physical Stay of thirty (30) days. This benefit is restricted to one payment of Hospital Cash Benefit per day and is subject to the maximum number of days per Policy specified in the Schedule of Benefits.
4. Transportation Fee Subsidy
This benefit is only available for Designated Plans.
We shall pay the Transportation Fee Subsidy in the amount shown on the Schedule of Benefits for each day on which the Insured receives medical treatment or undergoes surgery, tests, procedures or Confinement covered under Parts I-VI herein. This benefit is restricted to one payment of Transportation Fee Subsidy per day, regardless of the number of eligible procedures or treatments received or consultation visits made by the Insured, and is subject to the maximum number of days per Policy specified in the Schedule of Benefits.
5. Registered Chinese Medicine Practitioner Consultation and Chinese Medicines
We shall reimburse the Reasonable and Customary charges actually incurred for the Insured’s Out-patient consultation visit(s) with, and Chinese medicines prescribed by, a Registered Chinese Medicine Practitioner for a Covered Cancer. This benefit is restricted to one (1) visit per day and is subject to the maximum limit per visit and the maximum number of visits per Policy specified in the Schedule of Benefits.
6. Registered Physiotherapist Consultation
We shall reimburse the Reasonable and Customary charges actually incurred for the Insured’s consultation visit(s) with a Registered Physiotherapist for a Covered Cancer. This benefit must be recommended by a Registered Medical Practitioner. This benefit is restricted to one (1) visit per day and is subject to the maximum limit per visit and the maximum number of visits per Policy specified in the Schedule of Benefits.
7. Registered Dietician Consultation
We shall reimburse the Reasonable and Customary charges actually incurred for the Insured’s consultation visit(s) with a Registered Dietician for a Covered Cancer. This benefit must be recommended by a Registered Medical Practitioner. The benefit is restricted to one (1) visit per day and is subject to the maximum limit per visit and the maximum number of visits per Policy specified in the Schedule of Benefits.
8. Psychological Counselling
We shall reimburse the Reasonable and Customary charges actually incurred for consultation visit(s) by the Insured and/or an Immediate Family Member with a Registered Psychologist or a Psychiatrist for Psychological Counselling in relation to the Insured’s Covered Cancer. This benefit is capped at one (1) visit for the Insured and one (1) visit for one (1) Immediate Family Member per day, and is subject to the maximum limit per visit and the maximum number of visits per Policy specified in the Schedule of Benefits.
9. Preventive Check-up for Immediate Family Members
We shall reimburse the Reasonable and Customary charges actually incurred for Diagnostic Tests undertaken by Immediate Family Members for health screening, which shall be related directly to the type of Covered Cancer that the Insured is Diagnosed with, as recommended by a Registered Medical Practitioner within one hundred and twenty (120) days following the first Diagnosis of any Covered Cancer that the Insured is Diagnosed with. This benefit covers up to two (2) Immediate Family Members and is subject to the maximum limit per Policy specified in the Schedule of Benefits.
10. Home Nursing
We shall reimburse the Reasonable and Customary charges actually incurred for Medically Necessary nursing services provided to the Insured by a Licensed or Graduate Nurse in the Insured’s home after the Insured’s Discharge from Hospital following Confinement or surgery covered under Part II herein. This benefit must be prescribed by the Insured’s attending Registered Medical Practitioner and relate directly to the Confinement of the Insured and/or surgery performed on the Insured for a Covered Cancer.
This benefit is restricted to nursing services provided by a maximum of one (1) Licensed or Graduate Nurse during any given time slot, and is subject to the maximum limit per day and the maximum number of days (during which nursing services are provided for all or part of the day) per Policy specified in the Schedule of Benefits. 11. Medical Appliances
Subject to the maximum limit per Policy specified in the Schedule of Benefits, we shall reimburse the Reasonable and Customary charges actually incurred for the purchase and / or rental of medical appliances related to Covered Cancer which are Medical Necessary and recommended by a Registered Medical Practitioner.
12. Wig and Voice Box Expenses
Subject to the maximum limit per Policy specified in the Schedule of Benefits, we shall reimburse the Reasonable and Customary charges actually incurred for the purchase of a wig and / or voice box for the Insured provided that the charges for chemotherapy and / or radiotherapy have been actually incurred and are payable under Part II herein.
PART VII COMPASSIONATE DEATH BENEFIT
Upon the death of the Insured, we shall pay to the Beneficiary the Compassionate Death Benefit as shown in the Schedule of Benefits provided proof of such death is furnished to the Company. If the Insured, whether sane or insane, commits suicide within one (1) year from the Issue Date or Commencement Date, whichever is later, our liability under the Policy will be limited to the refund of premiums paid (without interest) less any Policy Debt.
LIMITATIONS OF BENEFITS
We are not liable for any Confinement, surgery and/or medical treatment for which compensation or reimbursement is payable under any law, medical program, or insurance policy provided by any government, company or other insurer except to the extent that such charges are not reimbursed by such law, medical program or insurance policy.
If the Insured is Confined in a room of the class above Semi-Private Room, whether voluntarily or involuntarily, on any days of a Confinement, any reimbursable charges under Parts I-V herein in relation to such days of Confinement shall be reduced by multiplying an adjustment factor (“Adjustment Factor”). The Adjustment Factor is calculated by dividing the daily room charge of a Semi-Private Room in the Hospital admitted by the Insured by the daily actual room charge of each such days of Confinement.
If the relevant Reasonable and Customary charge for actual charges is incurred in the United States, the following limitations on benefits shall apply:
(a) The maximum aggregate amount paid or payable in respect of the benefits under Parts I-IV of the BENEFIT PROVISIONS and benefits payable under any Target Protection Benefit pursuant to Part V of the BENEFIT PROVISIONS (if applicable) for any one Covered Cancer under all cancer protection insurance policies (including this Policy) covering the Insured and issued by us will be capped at HK$/ MOP 2,000,000 / US$250,000. The Company shall have absolute discretion to determine whether an insurance policy covering the Insured falls within the definition of a cancer protection insurance policy for the purpose of this section; and
(b) The maximum aggregate amount paid or payable in respect of the benefits under Parts I-IV of the BENEFIT PROVISIONS and benefits payable under any Target Protection Benefit pursuant to Part V of the BENEFIT PROVISIONS (if applicable) under this Policy for any and all Covered Cancer will be capped at HK$/ MOP 2,000,000 / US$250,000.
Notwithstanding reduction of any benefits in accordance with the above, and for the avoidance of doubt, the Covered Cancer Limit and Lifetime Cancer Limit shall otherwise remain unchanged.
LIMITATIONS OF CONFINEMENT BENEFITS
For benefits relating to Confinement, the Confinement must be evidenced by a daily room/room & board charge by the Hospital. We will not be liable to pay any benefit:
(a) for more than one daily room/room & board charge for each day of Confinement; or (b) for any Confinement that is not a Reasonable and Customary Hospital Confinement.
REVISION OF BENEFIT STRUCTURE AND/OR LIMITATIONS
On any Policy Anniversary or renewal, by giving a thirty-one (31) days prior notice in writing by ordinary post to the Owner’s last known address in the Company’s records, the Company reserves the right to revise, amend or modify the benefit structure and/or restrictions/limitations and/or the premium, including but not limited to the Schedule of Benefits, and/or any other items of benefits or coverage as determined by the Company.
In the event that the Owner disagrees with such revision and notifies the Company in writing within thirty (30) days after such revision takes effect, this Policy and all its Supplementary Contracts attached hereto (if any) shall automatically terminate on the Premium Due Date following our receipt of such notice.
Any change of benefits or coverage under this Policy as requested by the Owner shall only take effect subject to the approval by the Company and on the Policy Anniversary or renewal.
An appropriate endorsement shall be issued following each revision together with the revised Schedule of Benefits. *** End of Page ***
EXCLUSIONS
Except for Compassionate Death Benefit under Part VII above, this Policy does not cover any Covered Cancer resulting directly or indirectly from or in respect of any of the following or any event which arises from the following:
(a) any tumour which is histologically classified as pre-malignant;
(b) abnormal lesions of cervix uteri classified as cervical intra-epithelial neoplasia grade I (CIN I) and grade II (CIN II); (c) any drug or alcohol abuse;
(d) any Pre-existing conditions;
(e) nuclear, biological or chemical contamination (NBC); and
(f) the Confinement, treatment, surgery and/ or charges relating to or caused directly or indirectly, wholly or partly, by any of the following:
(1) general check-up (whether with or without any positive findings(s) on the Insured), convalescence, custodial or rest care not related to the Covered Cancer; screening or checkups looking for the presence of Covered Cancer on a preventative basis or where there are no symptoms or history of Covered Cancer; vaccines for the prevention of Covered Cancer;
(2) disease or infection with any human immunodeficiency virus (HIV) and/or any HIV-related illness;
(3) any treatment, tests, service or supplies which is not Medically Necessary or any charges which exceed the Reasonable and Customary charges;
(4) narcotics used by the Insured unless taken as prescribed by a Registered Medical Practitioner;
(5) mental disorder, psychological or psychiatric conditions, behavioural problems or personality disorder unless such occurrence is covered by Psychological Counselling under Part VI.8;
(6) any congenital Covered Cancer gives rise to signs or symptoms, or was diagnosed, before the Insured attains seventeen (17) years of age;
(7) any services primarily for physiotherapy or for the investigation of signs and/ or symptoms with diagnostic imaging, laboratory investigation or other diagnostic procedures unless they are covered by Diagnostic Benefit under Part I; (8) non-medical services, including but not limited to guest meals, radio, telephone, photocopy, taxes, personal items,
medical report charges and the like;
(9) any experimental, unproven or unconventional medical technology/ procedure/ therapy or novel drugs/ medicines/ stem cell therapy not yet approved by the government, relevant authorities and/ or recognized medical association of the country or region where the treatment is sought;
(10) genetic testing undertaken to test for a genetic predisposition to Covered Cancer;
(11) any treatment modality undergone without a definite Diagnosis of the presence of Covered Cancer in the Insured’s body as per the definition specified; and
(12) over-the-counter medication and nutrient supplement not prescribed by a Registered Medical Practitioner. *** End of Page ***
CLAIM PROCEDURES
(1) NOTICE OF CLAIM
All cases of death must be notified immediately to us in writing. Other claims must be submitted to us within twenty (20) days after the date the covered event happens. Failure to give notice within such time shall not invalidate any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as reasonably possible. The claims against this Basic Policy and any Supplementary Contracts attached hereto are assessed independently of each other and it may lead to different claim decisions.
(2) FILING PROOF OF CLAIM
Affirmative proof of loss and any appropriate forms as required by us must be completed and furnished to us, at the claimant’s expenses, within ninety (90) days after the date the covered event happens, unless specified otherwise. We reserve the right to require any additional proof and documents in support of the claim. The original copies of the official statement of accounts and receipts showing the itemized expenses are required.
(3) MEDICAL EXAMINATION
We reserve the right to require any additional proof and request medical examination of the Insured. In case of death, we may require, if appropriate and legally allowable, an autopsy.
(4) CANCELLATION
If you or the claimant submits a claim which is in any respect fraudulent, unfounded, incorrect, incomplete or misleading, or if you or the claimant withhold any information or conspire with a third party to obtain a benefit from this Policy, we shall have the right to cancel this Policy immediately. In any of these circumstances, we shall also have the right to recover from you or the claimant any benefit we have already paid to you or the claimant in relation to any claim which is not eligible.
(5) DEDUCTION OF PREMIUM AT DEATH
If the Insured dies, any balance of the premium due for the full Policy Year in which death occurs shall be deducted from the proceeds payable under the Policy.
GENERAL PROVISIONS
THE CONTRACTYour Policy is a legally enforceable agreement between you and us. This Policy comes into force on the Issue Date provided you have paid the full amount of the first premium and have submitted a signed and dated application.
The plan name of the Basic Policy and the product and/or code name and form number of any Supplementary Contract attached hereto are shown under the Schedule of Benefits and Premiums of the Policy Information Page.
We rely on the information you provide in your application in deciding whether or not to accept your application. We also rely on such information to decide at our sole and absolute discretion whether or not to apply Special Terms to your Policy. We will treat all statements made in your application (in the absence of fraud) to be representations and not warranties.
If your application omits facts or contains materially incorrect or incomplete facts, we have the right to declare the Policy void. Alternatively, we may impose Special Terms on your Policy that will apply from the date on which the cover commences.
MISSTATEMENT OF AGE AND SEX
If the Insured’s age and sex was misstated in your application, the amount payable by us under your Policy will be adjusted at the time we make any payment under the Policy.
Where a higher premium would have applied on the basis of the correct age and sex, we will adjust the benefit payable based on what the premiums paid would have provided at the Insured’s correct age and sex.
Where a lower premium would have applied on the basis of the correct age and sex, we will refund any surplus premium paid without interest.
Where the Insured would not have satisfied our insurability requirements on the basis of the correct age and sex, we have the right to declare the Policy or the Supplementary Contract void (as the case may be) and our liability under the Policy or the Supplementary Contract (as the case may be) will be limited to return the premiums paid (without interest).
We have the right to require proof of the Insured’s age to our satisfaction at the time of processing any claim or payment of any benefit under your Policy.
INCONTESTABILITY
Except for fraud or non-payment of premiums, we will not contest the validity of this Policy after it has been in force during the lifetime of the Insured for a continuous period of two (2) years from the Issue Date or Commencement Date, whichever is later.
This “Incontestability” provision does not apply to any Supplementary Contract providing accident, hospitalisation or disability benefits.
SMOKING HABIT
This Basic Policy is issued or reinstated on the basis of the Insured’s declared smoking habits. If the Insured is a smoker as at the date of the application form for the Basic Policy or as at the date of the appropriate form for reinstatement of the Basic Policy but you and / or the Insured do not disclose the same to us in the relevant form, this Basic Policy shall be voidable by the Company notwithstanding any other provision of the Policy (including, but not limited to, any incontestability clause in this Policy).
MODIFICATIONS
No variation to this Policy (or any waiver of any term or condition of the Policy) will be binding unless evidenced by an endorsement signed by our duly authorized officer.
CURRENCY AND PLACE OF PAYMENT
All amounts payable under this Policy either to or by us shall be made in the currency shown on the Policy Information Page provided that we shall have the absolute discretion to accept payment in another currency. All amounts due from us will be
OWNERSHIP PROVISIONS
OwnerThe Owner is the only person entitled to exercise any right or privilege provided under this Policy.
Change of Ownership
While this Policy is in force, you may, without the consent of the Beneficiary or trustee, change ownership of this Policy by filing a written notice on the Company’s prescribed form. Any change of ownership of this Policy shall be conditional upon the satisfaction of customer due diligence and other applicable requirements under Anti-Money Laundering and Counter-Terrorist Financing Ordinance and other applicable guidelines, and any such change will not be effective until such change is evidenced by an endorsement issued by us. We are not responsible for any written notice of a change of ownership received by us pending issue of an endorsement.
If and when the Owner dies:
(a) If the Insured is 18 years old or above and no Contingent Owner is named, the Insured will become the Owner of this Policy.
(b) If the Insured is 18 years old or above and a Contingent Owner is named, the Insured will become the Owner of this Policy.
(c) If the Insured is less than 18 years old and a Contingent Owner is named, the Contingent Owner will become the Owner of this Policy.
(d) If the Insured is less than 18 years old and no Contingent Owner is named, the successor to the Owner’s estate will become the Owner of this Policy.
PAYMENT OF BENEFITS
During the lifetime of the Insured, all benefits (except death benefit) payable under the Policy will be paid to the Owner if the Owner is alive, otherwise to the Owner’s estate.
If the Insured dies, unless otherwise provided under applicable law, any death benefit payable under the Policy will be paid to the Beneficiary. If no Beneficiary survives the Insured, the death benefit and all other benefits, if any, will be paid to the Owner if the Owner is alive, otherwise to the Owner’s estate.
Payment of the death benefit and all other benefits payable under this Policy (or Supplementary Contracts) to the above person(s) in the manner pursuant to this clause shall be deemed a good and full discharge of the Company’s obligations under this Policy (or Supplementary Contracts).
CHANGE OF BENEFICIARY
While your Policy is in force and to the extent permitted by law, you may change the designated Beneficiary by sending a written notice to us on our Company’s prescribed form unless the previous designation specifies otherwise. A change of Beneficiary will not be valid unless:-
(a) such change has been confirmed by our Issuing Office in writing; (b) both you and the Insured are alive at the date of such confirmation; and (c) such change is evidenced by an endorsement issued by us.
We are not responsible for any written notice of a change of Beneficiary received by us pending issue of an endorsement.
GUARANTEED RENEWAL
Subject to all of the terms and conditions of this Policy, you have a guaranteed right to renew this Policy by advance payment of the appropriate annual premium on each Policy Anniversary during the lifetime of the Insured. We reserve the right to determine the terms and conditions for renewal. Unless otherwise specified, the premium is not fixed, and at the time of such renewal, we reserve the right to revise or adjust it according to our applicable premium rate for the attained age of the Insured at the time of such renewal, subject to other terms and conditions, if any, as set out in this Policy.
LIMITATIONS OF TIME FOR BRINGING SUIT
Subject to applicable law, any action at law or in equity to recover on this Policy shall only be brought within two (2) years from the date of the Company’s final decision in respect of any claim herein.
NO THIRD PARTY RIGHTS
A person who is not a party to this Policy (including, but not limited to, the Insured or the Beneficiary) has no right to enforce any terms of this Policy.
TERMINATION
This Policy shall automatically terminate on the occurrence of the earliest of the following: (a) the death of the Insured;
(b) the lapse of the Policy pursuant to the “Grace Period” clause under the PREMIUM PROVISIONS; and
(c) the date the aggregate amount paid in respect of benefits under Parts I-IV of the Benefit Provisions under this Policy reaches the Lifetime Cancer Limit.
On termination of your Policy, all benefits under all Supplementary Contracts (if any) will also terminate.
Termination of this Policy shall be without prejudice any claim arising prior to such termination unless otherwise stated. The payment to or acceptance of any premium hereunder subsequent to termination of this Policy shall not create any liability on the Company but the Company shall refund any such premium.
Notwithstanding the foregoing or anything else contained in this Policy, if on the date the Policy terminates pursuant to clause (b) above the Insured is Confined in a Hospital for a Covered Cancer, the Policy shall not terminate and coverage shall continue to be extended for an additional thirty (30) days of such Confinement without any premium payment, subject to any Coverage/Maximum Limit(s) shown in the Schedule Of Benefits or limitation(s) applicable to the covered benefit(s) in question.
CONFORMITY WITH LAW
Any provision of the Policy which on its Issue Date or Commencement Date, is in conflict with the laws of the country or place in which this Policy is delivered or issued for delivery is hereby amended to conform to the minimum requirements of such laws and shall not affect this Policy which shall remain in full force and effect.
GOVERNING LAW AND JURISDICTION
This Policy is governed by and shall be construed in accordance with the laws of such place where this Policy is issued (being Hong Kong or Macau, as the case may be). The courts of such place shall have non-exclusive jurisdiction to consider and determine any dispute or proceedings arising out of or in connection with this Policy.
PREMIUM PROVISIONS
PAYMENTWhile the Insured is living, all premiums are payable annually to us on or before their due dates. Payment shall be made to us either at our Issuing Office or to our authorized officer or cashier. The Company shall have the right to review and adjust the premium for this Policy from time to time. Any premium(s) paid to us but not yet due (“Prepaid Premium”) and/or any payment in excess of premium(s) currently due and payable (“Overpayment”) shall, subject to any maximum amount as determined by us from time to time, accumulate interest at such interest rates as we may determine from time to time. We reserve the right to reject any Prepaid Premium and/or Overpayment paid to us in excess of such maximum amount. You may withdraw the Prepaid Premium or Overpayment and/or any interest thereon in accordance with our procedures. The balance of any Prepaid Premium, Overpayment and / or interest thereon that is not withdrawn shall be automatically used to offset any premium due and payable which is not paid within the Grace Period.
DEFAULT
After payment of the first premium, failure to pay a subsequent premium on or before its due date will constitute a default in premium payment.
GRACE PERIOD
A Grace Period of thirty-one (31) days from the Premium Due Date shall be allowed for payment of each premium after the first premium during which this Policy shall remain in force. If a loss occurs within the Grace Period, the Company shall be entitled to deduct at its discretion any premium due and unpaid from the proceeds payable under this Policy. If any premium remains unpaid at the end of its Grace Period, the Policy shall be deemed to have lapsed and to have no further value as of the Premium Due Date in default.
REINSTATEMENT
If any premium is in default beyond the Grace Period, the Policy may be reinstated with the consent of the Company within five (5) years after (and excluding) the Premium Due Date in default subject to:
(a) a written application for reinstatement;
(b) production of evidence of insurability satisfactory to the Company; and
(c) all due and overdue levy on insurance premium (if any) as prescribed by the applicable laws are paid.
Such reinstatement shall only cover a loss or covered event which occurs after the latest Commencement Date. We will consider reinstatement by redating subject to our rules and regulations, including but not limited to the requirement that all claims for benefits hereunder prior to reinstatement be carried forward and included for purposes of applying the Covered Cancer Limit, the Lifetime Cancer Limit and any maximum limits shown on the Schedule of Benefits for benefits payable under the BENEFIT PROVISIONS to benefits payable under the reinstated Policy.
SCHEDULE OF BENEFITS OF
CANCER GUARDIAN 2 / CANCER GUARDIAN PEARL 2 – PLUS PLAN
Coverage/Maximum LimitLIFETIME CANCER LIMIT
(applicable to Benefits under Parts I - IV below) HK$/MOP3,000,000
COVERED CANCER LIMIT
(applicable to Benefits under Parts I - IV below, limit for every 3 consecutive years during the Term)
HK$/MOP1,000,000
I. DIAGNOSTIC BENEFIT Fully covered*
II. CANCER TREATMENT BENEFITS
1. Hospitalisation and Treatment Benefits
(a) Hospital Daily Room and Board Fully covered* (b) Attending Registered Medical
Practitioner’s Visit
Fully covered* (c) Intensive Care Unit Fully covered* (d) Surgical Expenses Fully covered* (e) Miscellaneous Hospital Expenses Fully covered* (f) Hospital Companion Bed Fully covered* 2. Day Treatment and Surgery Fully covered*
III. RECONSTRUCTIVE SURGERY BENEFIT Fully covered*
IV. MONITORING BENEFIT Fully covered*
V. TARGET PROTECTION BENEFIT Additional 50% of Covered Cancer Limit* for once per Policy
(applicable to eligible Stage IV Covered Cancer, Liver Cancer, Brain Cancer, Blood Cancer and Lymphoma only) VI. ADDITIONAL CARING BENEFITS
1. 1-Year Waiver of Premium Once per Policy
2. Daily Hospital Cash Benefit for ICU HK$/MOP1,000 per day up to 15 days per Policy 3. Daily Hospital Cash Benefit for Long Term
Hospitalisation
HK$/MOP500 per day up to 60 days per Policy 4. Transportation Fee Subsidy HK$/MOP500 per day up to 20 days per Policy 5. Registered Chinese Medicine Practitioner
Consultation and Chinese Medicines
HK$/MOP1,000 per visit per day up to 30 visits per Policy* 6. Registered Physiotherapist Consultation HK$/MOP600 per visit per day up to 20 visits per Policy* 7. Registered Dietician Consultation HK$/MOP600 per visit per day up to 20 visits per Policy* 8. Psychological Counselling HK$/MOP1,200 per visit per day up to 30 visits per Policy* 9. Preventive Check-up for Immediate Family
Members
HK$/MOP10,000 per Policy*
10. Home Nursing HK$/MOP1,000 per day up to 60 days per Policy* 11. Medical Appliances HK$/MOP5,000 per Policy*
12. Wig and Voice Box Expenses HK$/MOP3,000 per Policy* *** End of Page ***
Coverage/Maximum Limit VII. COMPASSIONATE DEATH BENEFIT HK$/MOP20,000
THE COVERAGE/MAXIMUM LIMIT MARKED WITH “*” DENOTES THAT EACH OF THE ITEMIZED EXPENSES AS SHOWN IN THE OFFICIAL STATEMENT OF ACCOUNTS OR RECEIPTS SUBMITTED TO THE COMPANY FOR REIMBURSEMENT IS SUBJECT TO THE REASONABLE AND CUSTOMARY CHARGES.
WORLDWIDE EMERGENCY ASSISTANCE SERVICES ENDORSEMENT
This Endorsement is attached to and forms a part of the Policy. Except as otherwise provided in this Endorsement, all terms, conditions, provisions and definitions of the Policy shall have full force and effect.
BENEFITS
While this Policy is in force, and subject to the terms, conditions and exclusions herein contained, we will provide the following coverages which will be organized and implemented using the means and services best adapted to the physical condition of the Insured by a service provider (“Provider”) engaged by us.
(a) EMERGENCY MEDICAL EVACUATION
If the Insured suffers a Serious Injury or Sickness commenced during the Insured's Trip outside the country or place of which the Insured was a permanent resident at the time the Trip commenced (being Hong Kong, Macau or the People’s Republic of China, as the case may be), and if, in the absolute opinion of the Provider or its authorized representative, it is judged medically appropriate with regard to relevant factors (such as the Insured’s medical situation and the treatments that the Insured has been undertaking), the Provider will organize emergency medical transport to the nearest medical facility that is adequately equipped to treat the Insured's medical condition. Depending upon the medical severity of the Insured's condition, the Insured will be transported by airplane, road or air ambulance, rail or other suitable and available means. Except as may be included under Covered Expenses (as defined herein), medical expenses, including but not limited to the cost of medical treatment at the nearest medical facility to which the Insured has been transported for treatment, are not covered hereunder.
(b) REPATRIATION OF REMAINS
If the Insured dies during a Trip, the Provider will organize the repatriation of the Insured's body to the country or place of which the Insured was a permanent resident at the time the Trip commenced (being Hong Kong, Macau or the People’s Republic of China, as the case may be). The costs of burial, embalming, casket and ceremonies are not covered unless this is mandatory under the local legislation.
(c) 24-HOUR WORLDWIDE TELEPHONE ENQUIRY SERVICES
While the Policy is in force, a 24-hour worldwide telephone enquiry service will be provided to the Insured for travel matters, before or during the Insured’s Trip.
The 24-hour worldwide telephone enquiry service is limited to telephone enquiry services in relation to travel matters. We will not be held responsible for any costs or expenses (including any medical or legal costs, and costs for any other services) incurred by the Insured and / or you arising out of or in relation to following any advice or referral given by or from the 24-hour worldwide telephone enquiry service.
The 24-hour worldwide telephone enquiry service is provided on a best-effort basis and may not be available due to logistical problems, such as time, distance, location, or any other factors that are not within the control of the Company or the Provider. Without prejudice to the provisions “GENERAL TERMS AND CONDITIONS” of this Endorsement, the Company or the Provider shall not be held liable or responsible for any damages or losses whatsoever suffered by the Insured for the failure, delay or omission in the delivery of this 24-hour worldwide telephone enquiry services.
The coverage hereunder for Covered Expenses under Items (a) and (b) above is subject to a maximum aggregate limit of HK$/MOP 5,000,000 or its equivalent of emergency assistance benefits payable under all policies insuring the same life issued by the Company or AIA Company Limited (whether in Hong Kong or otherwise), including this Policy, which are providing emergency assistance services coverage of the same or a similar type.
IN CASE OF MEDICAL EMERGENCY
In case of serious medical emergency the Insured must contact the Provider immediately. There will be assistance operators ready to respond twenty-four (24) hours a day.
After this preliminary contact the Provider’s medical team, in consultation with both the attending Registered Medical Practitioner(s) and / or the Insured's habitual Registered Medical Practitioner(s), will in their absolute discretion decide which means of medical transport and / or medical center and / or medical care is most appropriate to the Insured's medical situation.
In case of evacuation or repatriation due to covered Accident or Sickness the Provider will pay Covered Expenses directly to the medical transport organization.
Any expenses for a service not approved and arranged by the Provider or an authorized representative of the Provider shall not be covered under this Endorsement. However, the Company may at its absolute sole discretion consider reimbursing the expenses, or any part thereof, for services not approved or arranged by the Provider or an authorized representative of the Provider if it is proved to our satisfaction that the Insured and the Insured's traveling companions cannot, for reasons beyond their reasonable control, contact or notify the Provider during an emergency medical situation. Any such reimbursement will be limited to those expenses incurred for services that would have been provided by the Provider under the same circumstances.
When the Insured's transportation or that of other people traveling with the Insured is paid for by us, we are entitled to request any unused transportation tickets of the Insured or the Insured’s traveling companion(s), as the case may be.
GENERAL TERMS AND CONDITIONS
(a) In the event that authorization of payment and / or payment is made by the Company or the Provider or an authorized representative of the Provider for an emergency assistance claim which is not covered under this Endorsement, the Company or the Provider or an authorized representative of the Provider reserves the right to recover the said sum from the Insured.
(b) The Company or the Provider cannot be held liable for any default or delay in the execution of services in the event of strikes, riots, any act of sabotage or terrorism, civil or foreign war, release of heat or irradiation coming from the splitting of nuclei of atoms, radioactivity, other accidents or case of natural catastrophe.
All interventions by the Provider are conducted within the context of the national and international laws and regulations and are dependent on all necessary authorizations and permits being obtained from the relevant authorities.
(c) The coverage under this Endorsement shall automatically terminate on the occurrence of the earliest of the following:
i) termination of the Policy;
ii) taking up of permanent residency by the Insured in a jurisdiction other than the country or place of which the Insured was a permanent resident at the time the Trip commenced (being Hong Kong, Macau or the People’s Republic of China, as the case may be); or
iii) any specific loss for which any benefit of Repatriation of Remains is payable under this Endorsement. (d) The Provider or an authorized representative of the Provider is not our agent and we shall not be held liable or
responsible for the act or omission of such provider.
EXCLUSIONS
Exclusions of the Basic Policy and Supplementary Contracts (if any) do not apply and are replaced with the following for purposes of this Endorsement.
Benefits under this Endorsement will not be provided for any expenses or loss resulting in whole or in part from any of the following occurrences:
(a) War declared or undeclared, invasion, civil war, revolution, and any warlike operations;
(b) Treatment of alcoholism, or drug abuse or any other complications arising therefrom, or Accidents and / or illnesses caused by and whilst under the influence of drugs or alcohol;
(c) The Insured commencing his Trip contrary to medical advice, or with intention to obtain medical treatment or after a terminal prognosis has been made;
(d) Suicide, attempted suicide or intentionally self-inflicted Injury;
(e) The Insured engages or takes part in hang-gliding, parasailing, parachuting or any sports undertaken on a professional or competitive basis;
(f) The Insured engaging in air-travel except flying as a fare-paying passenger in or on any aircraft operated by a commercial passenger airline on a regularly scheduled passenger trip over its established passenger route;
(g) The Insured engaging in services in any of the armed forces; (h) Violation or attempted violation of the law or resistance to arrest; (i) Pre-existing Conditions;
(j) Childbirth, pregnancy and its Complications of Pregnancy; (k) Mental or nervous disorders;
(l) Cosmetic or plastic surgery, or any elective surgery; or
(m) Any loss that is covered by any other existing insurance scheme, government program or which will be paid or refunded by a hotel, airline, travel agent or organizer, or any other providers of travel and / or accommodation.
MODIFICATIONS AND CANCELLATION
We reserve the absolute right and discretion to determine, specify and amend the scope and conditions of any of the coverage under this Endorsement or to terminate or cancel any of them at any time without notice.