243：平安综合医疗团体健康保险

Policy Clauses of Ping An Comprehensive Medical Group Health Insurance of China Ping An Life Insurance Co., Ltd.(Ping An Life Insurance [2003] No.209, filed to the CIRC in April 2004)Article 1 Constitutes of the Insurance ContractThe insurance policy or other insurance certificate and its attached clauses, the application form, the list of persons insured and other application documents related to the Contract, and valid statements, endorsements, attached riders, and other written agreements constitut e this insurance contract (hereunder referred to as the “Contract”). Article 2 CoverageAny government agency, corporate or public institution, and other group may apply for effecting the Contract as the applicant for its employees and their spouses and children. Article 3 Insurance LiabilitiesDuring the effective period of insurance liabilities of the Contract, the Company will cover the following benefits as agreed at the time of insurance:Where the insured suffers an accidental injury or disease, takes treatment at hospital and incurs any medical expense, the Company will pay the comprehensive medical benefit for each medical expense falling within the agreed scope of benefit according to the agreed proportion, but the total amount of benefit shall not exceed the amount of comprehensive medical benefit stipulated in the Contract.When the total amount of comprehensive medical benefit reaches his/her insured amount, the Company will terminate the insurance liabilities for the said insured.Article 4 Establishment and Management of Comprehensive Medical Insured AmountThe Company will establish the comprehensive medical insured amount for the insured as agreed after deducting the management fee from the premium paid by the applicant. The comprehensive medical insured amount consists of the insured amount for individual comprehensive medical insurance and the insured amount for mutual comprehensive medical insurance. The insured amount for individual comprehensive medical insurance is used by the insured him/herself, and the insured amount for mutual comprehensive medical insurance is used by all persons insured as agreed.During the period of insurance, the comprehensive medical insured amount may be added up, and accrue the interest according to the corresponding demand deposit rate of bank.At the expiry of the Contract, the Company will refund the balance of comprehensive medical benefit to the applicant or carry over it to the next insurance year as agreed.During the effective period of insurance liabilities of the Contract, where the insured dies from an accidental injury or disease (excluding cases stated in Article V of the Contract), the Company will refund the balance of individual comprehensive medical benefit for the said insured to the applican t or to the insured‟s family after approved by the applicant.Article 5 ExclusionsWhere the insured pays any medical expense in any of the following cases, the Company will not cover any of the benefits:(I) The policyowner willfully kills or injures the insured;(II) The insured willfully commits a crime or resists arrest, commits suicide or injures him/herself;(III) The insured has any fighting, or alcohol, drug or any other intoxicating substance abuse or addiction;(IV) The insured has any drunken or unlicensed driving or drives an unlicensed vehicle;(V) War, military action, riot or armed rebellion;(VI) Nuclear explosion, nuclear radiation or nuclear pollution.(VII) The insured takes, applies or injects medicine without the permission of doctors;(VIII) The insured suffers from a venereal disease, AIDS or is being infected with HIV (HIV is positive);(IX) The insured suffers from any exclusive disease specially stipulated in the insurance policy.Where the insured dies due to any of the cases above, the Company will refund the balance of individual comprehensive medical benefit for the said insured to the applicant, upon which the insurance liabilities for the said insured will terminate.Article 6 The Insurance PeriodThe insurance period of the Contract is one year.The insurance liabilities assumed by the Company will commence from the zero hour of the date when the Company agrees to underwrite, collects the premium and issues the insurance policy, and end by the 24th hour of the termination day stipulated in the Contract, Beijing Time shall be adopted.Article 7 Insured Amount and PremiumThe insured amount and premium of the Contract shall be determined according to the coverage and the management fee agreed between the applicant and the Company, andstated in the insurance policy.Article 8 Faithful RepresentationWhen the Contract is concluded, the Company shall definitely explain the contents of clauses in the Contract to the applicant, especially exclusions, and ask the applicant in written about the relevant conditions of the insured, and the insured shall make a faithful statement.Where the applicant or the insured willfully conceals facts, fails to perform the duty of faithful representation, or negligently fails to perform the duty of faithful representation, and it is enough to have an influence on the Company‟s decision to underwrite, the Company will have right to terminate the Contract or cancel the insurance qualification of the said insured.If the applicant or the insured willfully fails to perform the duty of faithful representation, for any insurance accident occurring before the termination of the Contract or the cancellation of insurance qualification of the said insured, the Company will neither cover the benefit nor refund the premium or the balance of comprehensive medical benefit.Where the applicant or the insured negligently fails to perform the duty of faithful representation, and it has a significant influence on the occurrence of insurance accident, for any insurance accident occurring before the termination of the Contract, the Company will not cover any of the benefits, but refund the balance of comprehensive medical benefit to the applicant; and for any insurance accident occurring before the cancellation of the insurance qualification of the insured, the Company will not cover any of the benefits, but refund the balance of individual comprehensive medical benefit for the said insured to the applicant.Article 9 Designation and Change of the Beneficiary“The comprehensive medical benefit” is the insured him/herself, and the Company does not accept any designation or change.Article 10 Notice of Insurance AccidentThe applicant, the insured or the beneficiary shall notify the Company within 5 days after he/she knows or ought to know the occurrence of insurance accident. Otherwise, the applicant, the insured and the beneficiary shall bear the Company‟s overpaid survey, inspection and other expenses as a result of delay in notification. But those caused by any act of God are excluded.Article 11 Claim(I) Claim for “comprehensive medical benefit”The beneficiary for “comprehensive medical benefit” shall fill in the claim form as the claimant within 10 days after this treatment is over, and claim against the Company for the “comprehensive medical benefit” by providing the following certificates and materials.1. The applicant‟s certificate and insurance policy or any other insurance document;2. The insured‟s household register certificate or identify certificate;3. The i nsured‟s medical diagnosis report and original documents for medical expenses,and if the insured is hospitalized for treatment, the certificate for entering/exiting the hospital shall also be provided;4. Any other certificate and material related to iden tification of the insurance accident‟snature, reason etc. available from the beneficiary.Where the beneficiary applies for the “comprehensive medical benefit”, if having obtained part of compensation for medical expenses from other channels, the Company will cover the benefit for only the rest part of medical expenses as provided in the Contract. Where the beneficiary cannot provide original documents for medical expenses by reason of applying for compensation for medical expenses from other channels, the beneficiary shall also provide the copy of documents for medical expenses and relevant certificates and indicate the paid proportion and amount, with the payer‟s seal affixed.(II) After receiving the claim form for the benefit and the relevant certificates and materials above from the claimant, for those assuredly falling within the insurance liabilities, the Company shall pay the benefit within 10 days after reaching an agreement on the amount of benefit with the claimant. And for those falling beyond the insurance liabilities, the Company will issue a notice of rejection to the claimant.(III) If the amount of benefit for those falling within the insurance liabilities cannot be ascertained within 60 days after the Company receives the claim form for the benefit and the relevant certificates and materials above from the claimant, the Company will pay the ascertainable minimum amount in advance according to the existing certificates and materials, and the Company will pay the corresponding balance after finally ascertaining the amount of benefit.(IV) The beneficiary‟s right to claim against the Company for the benefit will cease to exist if not exercised within 2 years after he/she knows or ought to know the occurrence of insurance accident. But if there is any of the following cases when the beneficiary claims for the benefit, the Company will not cover any of the benefits:1. The applicant fails to renew the Contract upon its expiry, and the balance ofcomprehensive medical benefit has been refunded to the applicant;2. The Contract remains in force or renews after its maturity, the insured‟s personalcomprehensive medical benefit is zero and the applicant does not agree to pay the benefit out of the mutual comprehensive medical benefit;3. Th e insured dies during the period of insurance, the balance of the insured‟s personalcomprehensive medical benefit has been refunded to the applicant or to the insured‟s family upon the consent of the applicant, and the applicant does not agree to pay the benefit out of the mutual comprehensive medical benefit;4. The applicant or the insured willfully or negligently fails to perform the duty offaithful representation, and the Company has terminated the Contract or cancelled the insurance qualification of the said insured;5. The applicant applies for surrender, and the balance of comprehensive medicalbenefit has been refunded to the applicant.Article 12 Change of Persons Insured(I) The applicant, if needing to add any person insured due to the turnover of on-the-job employees, shall notify the Company in written, and the Company will commence to cover the benefits after underwriting and collecting the relevant premium.(II) If during the effective period of insurance liabilities of the Contract, any on-the-job employee participating in this insurance is dismissed, and the Company‟s insurance liabilities for the said insured and his/her spouse and all children participating in this insurance as of the date of his/her dismissal, the Company will refund the balance of the said insured and his/her spouse and children‟s personal comprehensive medical benefit to the applicant. But except when the dismissed person‟s spouse and children are also the applicant‟s employees.(III) If during the effective period of insurance liabilities of the Contract, any employee participating in this insurance dissolves the marriage relationship with his/her spouse participating in this insurance, the applicant may notify the Company in written, and cancel the qualification of this employee‟s spouse as the insured, the Company…s insurance liabilities for this employee‟s spouse will terminate as of the date when the marriage relationship is dissolved, the Company will refund the balance of this employee‟s spouse‟s personal compr ehensive medical benefit to the applicant. But except when this employee and his/her spouse are both the applicant‟s employees.(IV) When the number of persons insured in the Contract is less than 5, or lower than 75% of persons having the qualification for participating in the insurance, the Company will have right to cancel the Contract, and refund the balance of comprehensive medical benefit to the applicant.Article 13 Change of AddressIf the applicant‟s residence or correspondence address changes, he/she shall duly notify the Company in written, and if the applicant fails to notify in written, the Company shall send the relevant notice to the last residence address stated in the Contract.Article 14 Policy AlterationDuring the effective period of the Contract, the relevant contents of the Contract may be changed after negotiation of the applicant and the Company. When the Contract is changed, the Company shall endorse or attach riders onto the original insurance policy or other insurance certificate, or conclude a written change agreement with the applicant.Article 15 Process for the Applicant’s Cancellation of ContractDuring the effective period of insurance liabilities of the Contract, the applicant may request to terminate the Contract by written notice.(I) The applicant shall provide the following certificates and materials at the time of requesting to cancel this Contract:1. The applicant‟s certificate and insurance policy or any other insurance document;2. The application for cancellation of the contract.(II) Where the applicant requests to cancel the Contract, the insurance liabilities will terminate as of the date when the Company receives the application for cancellation of the contract, and the Company will refund the balance of comprehensive medical benefit to the applicant within 30 days after receiving the certificates and materials above.Article 16 Dispute ResolutionDuring the performance of the Contract, any dispute occurring between both parties may be resolved through negotiation; if failing to reach an agreement, both parties may institute a law suit in the court.Article 17 Paraphrase“The Company” refers to China Ping An Life Insurance Co., Ltd.“Group”means a legal group organized by 5 or more persons not for the purpose of purchasing insurance within the territory of the P. R. of China. It covers state organs, universities and colleges, corporate or public institutions, trade organizations, trade unions etc.“The applicant” refers to the unit applying for insurance.“The insured” refers to the persons stated in the list of persons insured attached to the Contract.“Spouse”refers to any person having a legal marriage relationship with the applicant‟s employee participating in this insurance.“Children”include legitimate children, illegitimate children, foster children and stepchildren having foster relationship“Family”consists of the insured‟s family, spouse and children.“Personal injury accident” means an exotic, sudden, unintentional, non-disease objective event bringing an injury to the insured‟ body.“Hospital” means a hospital appointed by the Company or a public hospital at the level of district/county or above lawfully operating within the territory of the P. R. of China, but excluding medical institutions mainly serving for clinic, rehabilitation, nursing, recreation, convalesce, abstinence from drinking or drugs or similar purposes. Such a hospital musthave medical equipment in accordance with the installment standard of the relevant national hospital administrative rules, and have qualified physician and nurses at the hospital providing medical and care services in 24 hours of a whole day.“Range of payment” means the scope of insurance liabilities assumed by the Company jointly determined on the basis of the deductible for supplementary hospitalization medical expense and the limit for supplementary hospitalization medical expense as agreed between the applicant and the Company.“Medical expense”means any reasonable and necessary expense incurred for the insured‟s taking outpatient, emergency or hospitalization treatment at hospital, including machine expenses, treatment fees, inspection and test fees, special examination and treatment fees, ambulance charges, surgical expenses etc.The comprehensive medical insured amount consists of the insured amount for individual comprehensive medical insurance and the insured amount for mutual comprehensive medical insurance. The balance of personal comprehensive medical benefit means the difference between the total amount of personal comprehensive medical benefit and the total amount of comprehensive medical benefit paid out of the personal comprehensive medical benefit. The balance of mutual comprehensive medical benefit refers to the difference between the total amount of mutual comprehensive medical benefit and the total amount of comprehensive medical benefit paid out of the mutual comprehensive medical benefit.“AIDS” means Acquired Immure Deficiency Syndrome.“HIV” means Acquired Immure Deficiency Syndrome Virus.The definition of Acquired Immure Deficiency Syndrome shall follow the definition of the WHO, for example, if a HIV or its antibody is found in the blood sample, the insured may be determined as being infected with AIDS or HIV.“Corresponding bank demand deposit rate” means the residential demand savings deposit rate announced by the PBOC.。