中国人民健康保险股份有限公司关爱专家短期重疾(推荐版)团体疾病保险(0)

PICC Health Insurance Co. Ltd.Care Expert - Group Short-term Critical Illness Insurance(Recommended Version)(These conditions and the general conditions of Short-term Illness Insurance constitute the insurance conditions of the insurance contract.) Code：2603011 Liabilities and Exclusions1.1 Sum Insured The Sum Insured is concluded as per agreement reached bythe Policyholder and the Insurer and is stated in the policy.Once concluded, the Sum Insured shall not be changedduring the Insurance Period of the Policy.1.2 Insurance Liability The Insurance Period of the Policy is one year. During theInsurance Period, the Insurer shall bear following liabilities:Critical Illness Benefit In the event that an accidental injury occurs to the Insured after the Insurer starts to bear insurance liability or a non-accidental incident occurs to the Insured 90 days thereafter (if the policy is renewed after the Insurer starts to bear renewed insurance liability), and causes critical illness (es) stated in the Policy to the Insured for the first time, the Insurer shall pay the Sum Insured as Critical Illness Benefit and the coverage of the Policy for the particular Insured Person shall terminate.In the event that a non-accidental incident occurs to the Insured within 90 days after the Insurer starts to bear insurance liability (renewed policy excluded), and causes critical illness (es) stated in the Policy to the Insured for the first time, the Insurer shall pay a sum as Critical Illness Benefit on the basis of the sum of premium paid for the particular Insured Person and the coverage of the Policy for him/her shall terminate.Death Benefit In the event that a non-accidental incident occurs to theInsured 90 days after the Insurer starts to bear insuranceliability (if the policy is renewed, after the Insurer starts tobear renewed insurance liability), and results in the death ofthe Insured, the Insurer shall pay the Sum Insured as DeathBenefit and the coverage of the Policy for the particularInsured Person shall terminate.In the event that a non-accidental incident occurs to theInsured within 90 days after the Insurer starts to bearinsurance liability (renewed policy excluded), and results inthe death of the Insured, the Insurer shall pay a sum asDeath Benefit on the basis of the sum of premium paid forthe particular Insured Person and the coverage of the Policyfor him/her shall terminate.1.3 Exclusions The Insurer shall bear no benefit liability in the event thatthe illness, the status of illness or the operated surgery iscaused to the Insured as the result of any following reasons:1)The Insured Person is killed or injured intentionally bythe Policyholder or the Beneficiary;2)Intentional self-inflicted injury, committing criminalcrimes intentionally, resistance to arrest;3)Substance abuse by ingesting, taking or injecting drugs;4)Driving under the influence of alcohol, driving without aValid Driving License, or driving an automotive vehiclethat is not validly licensed;5)Infected by HIV virus or suffering from AIDS;6)Wars, military conflicts, riots or armed insurrection;7)Nuclear explosion, nuclear radiation or nuclearpollution;8)Hereditary diseases, congenital malformation,deformation, and chromosomal abnormality.If any reason mentioned above caused the death or criticalillnesses covered by the Policy to the Insured, the Policyvalidity for this particular Insured Person shall terminateand the Insurer shall refund the unearned premium afterprocessing fee is deducted.2 Other Issues2.1 Change of theInsured If the Policyholder requests to add new Insured Persons, the Policyholder shall notify the Insurer in writing. The liabilities shall start at the time as agreed in the endorsement after consent of the underwriter and collection of premium. If the Policyholder needs to apply for canceling thecoverage of an Insured Person, a written notice shall be sent to the Insurer and the qualification of the Insured Person shall terminate on the day when the notice is received. If the termination date requested by the Policyholder is later than the arrival date of the notice, the Insured Person’s coverage shall terminate from 00:01a.m. of the termination date. The Insurer shall refund the unearned premium for the specific Insured Person after deducting processing fee.If a covered loss has already occurred to the Insured Person, the Policyholder shall not apply for the cancellation of the Policy.If the number of the Insured is fewer than 8 or lower than 75% of the number of the people eligible for the Policy, the Insurer has the right to cancel the Policy and refund the unearned premium after deducting processing fee.2.2 Benefit ApplicationDocumentation The Claimant shall provide following materials upon claim application and the Insurer has the right to keep the original or duplicated copies of the materials:Documents for Critical Illness Benefit 1)Proof of the identification of the Beneficiary;2)Certificate of diagnosis, prescriptions, medical record,and microscopy, blood test, imaging and other scientific examination reports essential for disease diagnosisissued by the hospital;3)Other proofs and materials relevant to the nature, cause,etc. of the Insured Incident.Documents for Death Benefit 1)Proof of the identification of the Beneficiary;2)Proof of the annulment of the household register of theInsured Person;3)Death certificate of the Insured Person issued by thepolice or hospital;4)Other proofs and materials relevant to the nature, cause,etc. of the Insured Incident.2.3 Special Notice The accessory policy of this Policy is Accessory Care Expert-Group Accidental Injury Insurance (RecommendedVersion) of PICC Health Insurance Co., Ltd.The validity of this Policy is bound by that of the accessory policy and shall terminate upon the termination of the latter.Definitions1 Processing Fee Refers to the average sum of the operation expense andcommission on each policy. The processing fee is 25% of thepremium.2 UnearnedPremium: Formula: Annual Premium * (1-25%) * (Number of days from current date to expiration date/365)3 Force Majeure Refers to objective circumstances that are unforeseeable,unavoidable and insurmountable.4 Attained Age Refers to the age calculated based on the date of birth recorded inlegal identification documents.5 AccidentalInjury Refers to the injury caused by accidental incident(s) that is external, eruptive, unintentional, and non-disease related.6 DrivingWithout AValid DrivingLicense Refers to one of following situations:1)Driving without a legally issued driving license;2)Driving at the time while the driving license is legallydetained;3)The vehicle driven does not match the vehicle type registeredin the license;4)Driving with an un-inspected driving license or expireddriving license;5)Other situation that the public traffic administrationdepartments deems as driving without a valid driving license.7 Infected by HIVVirus orSuffering fromAIDS HIV Virus refers to human immunodeficiency virus, abbreviated as HIV in English. AIDS refers to acquired immune deficiency syndrome caused by HIV virus, abbreviated as AIDS in English. If the Insured Person’s blood sample or other samples test positive for HIV or HIV antibody, and no clinical features and other symptoms appear, this indicates that the Insured Person is infected by HIV virus; if distinct clinical features or other symptoms appear at the same time, this indicates that the Insured Person is suffering from AIDS.8 HereditaryDiseases Hereditary Diseases refers to the diseases caused by the mutation or aberration of germ plasm (chromosomes and genes) in germ cells or fertilized ovum, usually featuring a vertical pass fromparents to offspring.9 CongenitalMalformation,Deformation,andChromosomalAbnormality Refers to the born malformation, deformation, and chromosomal abnormality of the Insured Person. The relevant stipulations in the International Statistical Classification of Diseases and Health Related Problems (ICD-10) released by the World Health Organization shall be referred to as the standard for Congenital Malformation, Deformation, and Chromosomal Abnormality.10 Hospital Refers to medical institutions which are legally established andfall into Grade A of Level 2 or higher grade of the MedicalInstitutions Ranking System of the Ministry of Health of P.R.China, but do not include sanatorium, nursing center,rehabilitation center, abstinence center or drug treatment center,mental and psychiatric treatment center and union hospital orunion ward without relevant medical personnel or medicalfacilities founded by hospitals falling into Level 2 or Level 3 ofthe Medical Institutions Ranking System.11 Critical IllnessMalignancy That the Insured Person suffers from illnesses meeting following critical illness definitions shall be supported by the diagnosis of specialists.Malignancy refers to the disease in which the malignant cells grow and proliferate uncontrolled progressively, soak and destroy the normal tissues around and can metastasize to other parts of the body through veins, lymphatic and coelom. Through pathological examination and clinical diagnosis, these cells meet the standards for malignancy stated in the International Statistical Classification of Diseases and Related Health Problems (ICD-10) released by the World Health Organization.Following illnesses are not in the coverage scope of the Policy:1)Carcinoma in situ;2)Chronic lymphocytic leukaemia equivalent to Stage A inBinet Cancer Staging3)Hodgkin’s Disease equivalent to Stage I in Ann Arbor CancerStaging;4)Skin cancer (melanoma and skin cancer that hasAcute Miocardial InfarctionStroke Sequelametastasized);5)Prostate equivalent to Stage T1N0M0 or younger stages inTNM Cancer Staging;6)Malignancy acquired when being infected by HIV virus orsuffering from AIDS.Acute Miocardial Infarction means that the obstruction of coronary artery causes blood deficiency in relevant part of the heart which, in turn, results in the partial necrosis of cardiac muscle. The illness shall meet at least 3 of the following conditions:1)Typical clinical features, acute chest pain for instance;2)Latest cardiogram change indicating Acute MiocardialInfarction；3)The level of cardiac enzyme or troponin increasediagnostically, or change dynamically, which indicates Acute Miocardial Infarction;4)After the Insured begins to suffer from Acute MiocardialInfarction, checkups confirm that the performance of the left ventricle falls, the left ventricular ejectfraction decreases by 50%, for instance.Sequela of Stroke means that the paroxysmal cerebrovascular pathological changes cause cerebrovascular haemorrhage, embolism or infarction and results in the permanent dysfunction of the nervous system, which means that the Insured Person still suffers from at least one of following dysfunction features 180 days after the disease of stroke is diagnosed:1)The total loss of the function of one or more extremities;2)The total loss of the power of speech or mastication andswallowing function;3)The total loss of the capability of living on one’s own, notable to independently conduct 3 or more of the 6 Basic Daily Living Activities.Transplant Operation of Major Organs or Hematopoietic Stem Cell TransplantCoronary Artery Bypass Grafting (CoronaryEnd-stage Renal Disease (Uraemia Stage of Chronic Renal FailureSeverance of Multiple Transplant Operation of Major Organs refers to the allogeneic transplant operation of kidney, liver, heart or lungs due to the failure of relevant organs.Hematopoietic Stem Cell Transplant refers to the allogeneic transplantation of hematopoietic stem cells (including bone marrow stem cells, peripheral blood stem cells and umbilical cord blood stem cells) due to impairment or malignancy of the hematopoietic system.Coronary Artery Bypass Grafting refers to the coronary artery bypass grafting performed after thoracotomy for the treatment of serious coronary heart disease.Coronary stent implantation, cardiac balloon catheter expansion , laser and RF technology and other non –open-chest interventional surgeries, endoscopic surgery are not in the coverage scope of the Policy.End-stage Renal Disease means that both kidneys suffer from irreversible chronic renal failure and enter into the stage of uraemia, and the Insured Person has received at least 90 days of regular dialysis treatment or has received kidney implantation.Severance of Multiple Extremities refers to the complete severance of 2 or more extremities from the proximal end (the end connecting the trunk) to wrists or ankles as the result of diseases or accidents.ExtremitiesAcute orSub-acute Severe HepatitisBenign Brain TumorDecompensation Stage of Chronic Liver Failure The hepatitis virus causes diffuse necrosis of the liver tissue and acute liver failure, which shall be confirmed by serological or viral examinations , and the illness shall meet all following conditions:1)Severe jaundice or the jaundice rapidly turns severe;2)Hepatic encephalopathy;3)B-type ultrasonic or other imaging checkups show anfulminant liver atrophy;4)Progressive deterioration of hepatic function indicators.Benign Brain Tumor has caused the rise of intracranial pressure and such clinical features as papilledema, mental symptoms, epilepsy, kinaesthesia dysfunction and so on, and may endanger the life of the Insured Person. The benign brain tumor shall be confirmed by CT, MRI or PET and other imaging examinations and shall meet at least one of following conditions:1)The brain tumor has been completely or partially resected,which is performed after craniotomy;2)Radiation therapy has been performed to the brain tumor. Pituitary adenoma, cerebral cyst, cerebral vascular diseases are not in the coverage scope of the Policy.Decompensation Stage of Chronic Liver Failure refers to the liver failure caused by chronic liver diseases and shall meet all following conditions:1)Continuous jaundice;2)Ascites;3)Hepatic encephalopathy4)Congestive splenomegaly with hypersplenism or esophagealand gastric fundus varices.The liver failure caused by bibulosity or drug abuse is not in the coverage scope of the Policy.Encephalitis Sequela or Meningitis SequelaDeep ComaDeafness of Both Ears Encephalitis Sequela or Meningitis Sequela refers to the permanent dysfunction of the nervous system caused by encephalitis or meningitis. The permanent dysfunction of the nervous system means that the Insured Person still suffers from one or more of following dysfunction features 180 days after the disease of encephalitis or meningitis is diagnosed:1)The total loss of the function of one or more extremities;2)The total loss of the power of speech or mastication andswallowing function;3)The total loss of the capability of living on one’s own, notable to independently conduct 3 or more of the 6 Basic Daily Living Activities.Deep coma means that the Insured Person loses his/her consciousness due to diseases or accidental injuries and is not responsive to both external stimulation and internal need; the coma degree scores 5 or below 5 according to Glasgow coma scale; and the Insured Person has used the ventilator and other life support systems for more than 96 hours.Deep coma caused by bibulosity or drug abuse is not in the coverage scope of the Policy.Deafness of Both Ears means that the hearing of both ears is permanently and irreversibly lost due to diseases or accidental injuries, and the pure-tone average is larger than 90 db under the voice frequency of 500 Hz, 1000 Hz and 2000 Hz, which shall be confirmed by pure tone audiometry, acoustic immittance or auditory evoked potential and so on.The Insured Person shall at least attain the age of 3 when applying for the benefits and the certificate of diagnosis for hearing loss and proof of checkups shall be provided.Blindness of Both EyesParalysisHeart Valve SurgerySevere Alzheimer’s Disease Blindness of Both Eyes means that the eyesight of both eyes is permanently and irreversibly lost due to diseases or accidental injuries and the better one of both eyes shall meet at least one of following conditions:1)The eyeball is lost or extirpated;2)The rectified eyesight is lower than 0.02 (according tointernational standard visual acuity chart, the scores shall be converted if other visual acuity charts are used)3)The viewing radius is smaller than 5 degree.The Insured Person shall at least attain the age of 3 when applying for the benefits and the certificate of diagnosis for eyesight loss and proof of checkups shall be provided.Paralysis refers to the permanent total loss of the function of two or more extremities caused by diseases or accidents. The permanent total loss of the function of extremities refers to the ankylosis of two of the three major joints of the extremities, or the inability to control joint movements 180 days after the disease are diagnosed or 180 days after the accidental injuries occursHeart Valve Surgery means that the Insured Person has received the heart valve replacement or restoration performed after thoracotomy for the treatment of heart valve diseases.Severe Alzheimer’s Disease means that the progressive and irreversible transformation causes severe decline or loss of one’s intelligence. Clinical features may include obvious cognitive dysfunction, behavioral abnormality and decline of social acceptability and that the Insured Person’s daily life shall be under progressive and close guard. CT, MRI or PET and other imaging examinations shall confirm the severe Alzheimer’s disease, the Insured Person shall completely lose his/her capability of living on his/her own and be not able toSevere Cerebral InjurySevere Parkinson's DiseaseSevere Degree ⅢBurns independently conduct 3 or more of the 6 Basic Daily Living Activities.Neurosis and mental diseases are not in the coverage scope of the Policy.Severe Cerebral Injury means that an external mechanical force blows the head, causes injuries to major parts of the brain and results in permanent dysfunction of the nervous system. CT, MRI or PET and other imaging examinations shall confirm the severe cerebral injury. The permanent dysfunction of the nervous system means that the Insured Person still suffers from at least one of following dysfunction features 180 days after the severe cerebral injury occurs:1)The total loss of the function of one or more extremities;2)The total loss of the power of speech or mastication andswallowing function;3)The total loss of the capability of living on one’s own, notable to independently conduct 3 or more of the 6 Basic Daily Living Activities.Parkinson's Disease is a kind of neurodegenerative disease of the central nervous system; its clinical features include parkinsonism, ataxia and so on. Severe Parkinson's disease shall meet all following conditions:1)The state of illness is beyond the control of medication;2)The total loss of the capability of living on one’s own, notable to independently conduct 3 or more of the 6 Basic Daily Living Activities.Secondary Parkinson's syndrome is not in the coverage scope of the Policy.Severe Degree ⅢBurns means that the degree of the burns isⅢand the area with degree Ⅲburns accounts for 20% or more of the total body surface area, which shall be calculated accordingSevere Primary Pulmonary HypertensionSevere Motor Neuron DiseaseLoss of SpeechSevere Aplastic Anaemia to Chinese Rule of Nines.The continuous pressure increase, which is caused by unidentified reasons, of the pulmonary artery, develops progressively into chronic disease, which has caused permanent and irreversible limitations on the capacity of conducting physical activities; the Insured Person enters into the Degree IV of the Status of Heart Function of US New York Heart Association and the average pressure of the pulmonary artery is over 30 mmHg when he/she is under resting state.Severe Motor Neuron Disease is a kind of progressive and degenerative disease of the motor neuron of the central nervous system, including progressive spinal muscular atrophy, progressive bulbar paralysis, primary lateral scleosis, amyotrophic lateral sclerosis. The Insured Person shall completely lose his/her capability of living on his/her own and be not able to independently conduct 3 or more of the 6 Basic Daily Living Activities.Loss of Speech means that the Insured Person completely loses his/her power of speech due to diseases or accidental injuries and cannot rehabilitate through current existing medical therapeutics. The loss of speech caused by mental factors is not in the coverage scope of the Policy.The Insured Person shall at least attain the age of 3 when applying for the benefits and the certificate of diagnosis for loss of speech and proof of checkups shall be provided.Severe Aplastic Anaemia refers to the anaemia, neutropenia and platelet decrease caused by chronic and progressive bone marrow failure, and shall meet all following conditions:1)The diagnosis of severe aplastic anaemia is supported bySurgery To AortaEnd-stage Chronic Respiratory FailureSystemic-Lupus -Erythematosusexaminations through bone marrow puncture or bone marrow biopsy;2)The peripheral blood shall meet all following threeconditions:a.The absolute value of neutrophilic granulocyte≤0.5×109/Lb.Reticulocyte＜1%;c.The absolute value of platelet≤20×109/L.Surgery To Aorta refers to the resection, replacement, restoration of ill or impaired aorta performed after thoracotomy for the treatment of the illness of aorta. The aorta refers to the thoracic aorta and abdominal aorta, not including the branches of the thoracic aorta and abdominal aorta.Percutaneous transluminal angioplasty is not in the coverage scope of the Policy.The following 6 critical illnesses are not included in the scope of The Regulation on Illness Definitions for Critical Illness Insurance of the Insurance Association of China.End-stage Chronic Respiratory Failure refers to the respiratory failure caused by chronic diseases of the respiratory system. The diagnosis of end-stage chronic respiratory failure shall be supported by all following conditions:1)FEV (Forced Expiratory Volume) 1 is less than 1 liter;2)Resistance rise of respiratory tract, rise to at least 0.5 kPa/l/s;3)The residual volume accounts for 60% of TLC (Total LungCapacity);4)Intrathoracis air volume rise above 170 (percentage of thebase value);5)PaO2<60mmHg，PaCO2>50mmHg.Systemic Lupus Erythematosus is a kind of autoimmune disease that affects multiple systems caused by multiple factors, featuringNephritisSevere Multiple SclerosisSevere Muscular Dystrophy a great number of antibodies and immune complexes that can cause lesions to tissues.Systemic-Lupus-Erythematosus Nephritis is a kind of complication when systemic lupus erythematosus affects the kidney. This Policy is only liable for Type III to Type V of Systemic-Lupus-Erythematosus Nephritis defined by WHO, other type of lupus erythematosuses, such as discoid lupus erythematosus and lupus erythematosus which only affects blood and joints, are not in the coverage scope of the Policy.The Types of Systemic-Lupus-Erythematosus Nephritis Defined by World Health Organization:Type I (minimal change type) Negative proved by microscopy, urine normalType II (mesangial change type) Medium albuminuria, occational change of urinary sedimentType III (focal and segmental proliferative type) Albuminuria, change of urinary sedimentType IV (diffuse proliferative type) Acute nephritis with change of urinary sediment and/or nephrotic syndromeype V (membranous type) Nephrotic syndrome or heavy albuminuriaSevere Multiple Sclerosis is a kind of disease featuringmulti-focal demyelinative change of the white matter (demyelination) of the central nervous system, which may sometimes affects the gray matter. This Policy is only liable for following condition: the multiple sclerosis causes lesions to the nervous system and makes the Insured Person completely lose his/her capability of living on his/her own and not able to independently conduct 3 or more of the 6 Basic Daily Living Activities.Severe Muscular Dystrophy refers to the degenerative change of a group of muscle. Its clinical features include muscular weakness and muscular atrophy not related with the pathological change ofAcute Hemorrhagic Necrotizing PancreatitisCrohn's Disease the nervous system. This Policy is only liable for following condition: the muscular dystrophy makes the Insured Person completely lose his/her capability of living on his/her own and not able to independently conduct 3 or more of the 6 Basic Daily Living ActivitiesAcute Hemorrhagic Necrotizing Pancreatitis means that the Insured Person has received abdominal surgery due to acute hemorrhagic necrotizing pancreatitis in order to clear the necrotic tissues, excise focuses or resect the pancreas. Acute hemorrhagic necrotizing pancreatitis caused by drunk drinking or the treatment through celioscopy is not in the coverage scope of the Policy.Crohn's Disease refers to a kind of chronic granulomatous enteritis. The ill state of Crohn's disease the Insured Person suffers from must have caused the formation of fistulas complicated by ileus or have caused intestinal perforation which can bring acute peritonitis. The diagnosis of the Crohn's disease shall be supported by colonoscopy and tissue pathological analysis.12 Specialist The “Specialist” mentioned in the entry of Critical Illness shallmeet all following standards:1)holding a valid Certificate of Licensed Physician of P.R.China;2)holding a valid Certificate of Practicing Physician of P.R.China which is registered and renewed on time in relevantadministration departments;3)holding a valid certificate of attending physician’s title orhigher title of P.R. China;4)practicing in the relevant department of Level 2 or highergrade hospitals for at least 3 years.13 Total Loss ofExtremityFunction Total Loss of Extremity Function refers to the ankylosis of two of the three major joints of the extremities, or the inability to control joint movements. Extremities refer to the entire upper extremitiesincluding the shoulder joint, and the entire lower extremities including the hip joint.14 Total Loss ofPower of Speechor Masticationand SwallowingFunction Total Loss of Power of Speech refers to the inability to constitute any three of the four sounds that constitute speech (labial, dental, palatal and velar), or the vocal cords have been completely excised, or aphasia has developed as the result of the injury to the brain’s speech center.Total Loss of Mastication and Swallowing Function refers to organic impairment or dysfunction due to causes other than the teeth, causing the inability to chew or swallow, and inability to ingest or swallow anything but liquid food.15 6 Basic DailyLivingActivities The “6 Basic Daily Living Activities” mentioned in the entry of Critical Illness refers to:1)dressing: to be dressed and take off one’s clothes on one’sown;2)moving: to go from one room to another on one’s own;3)acting: to go to bed or get off bed on one’s own;4)going to W.C.: to relieve one's bowels on one’s own;5)eating: to take food that have been prepared from bowls orplates and put it into the mouth on one’s own;6)bathing: to have a shower or tub on one’s own.16 Permanent andIrreversible The “Permanent and Irreversible” in the entry of Critical Illness means that the patient cannot rehabilitate after 180 days of substantial medical treatment through current existing medical therapeutics from the day when the illness is diagnosed or the accidental injury occurs.。