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1、保险期间：2016年07月31日 2017年07月30日Insured Period:From July.31st 2016 to July.30st 2017嘉会诊所保险福利宣讲会 JIA HUI CLINC Employee Benefits Insurance Communication内容 Contents阳光人寿简介 Sunshine Insurance Introduction保险福利及责任 Insurance Benefits&Liability索赔流程及注意事项 Claim Procedure and Special NotesQ&A阳光人寿简介Sunshine Insuran
2、ce Introduction阳光保险集团 Sunshine Insurance Group 阳光保险集团股份有限公司，是中国500强企业、中国服务业100强企业，集团注册资本金67.1059亿元人民币。公司股东实力强大，涉及行业广泛，股权结构合理，符合现代企业制度。目前拥有阳光财产保险股份有限公司、阳光人寿保险股份有限公司、阳光资产管理股份有限公司等多家专业子公司。阳光人寿保险成立于2007年12月17日，是主要经营人寿保险、健康保险和意外伤害保险等一切人身险业务的全国性专业寿险公司，注册资本金91.71亿元人民币。阳光人寿成立以来发展势头良好，公司价值不断提升。目前阳光人寿已有32家二级机
3、构开业运营，三四级分支机构700余家。阳光，未来 诞生于21世纪中国改革开放的进程中，阳光保险的发展理念以及水准在构建之初就已臻于成熟。阳光保险坚持“高起点组建，远战略发展”的原则，以阳光文化为指引，始终把坚持品质、市场能力、盈利能力、可持续发展和客户满意作为一切工作的指南，不断培育杰出的风险管理能力，强大的市场拓展能力和卓越的客户服务能力。随着保险经营环境的变化，阳光保险时刻锐意创新。她的轨迹凝重有加，她的未来风光无限。保险福利及责任 Insurance Benefits&LiabilityGroup Insurance Benefits Overview团体保险福利概览Term-Life
4、Insurance定期寿险Death due to disease疾病死亡AD&D Insurance意外伤害险Death due to accident意外死亡Disability due to accident意外残疾Dread Disease重大疾病30 kinds of Critical illness30种重大疾病Medical Insurance医疗保险Outpatient+Inpatient 门急诊+住院非医疗险Non-Medical Insurance团体定期寿险&意外伤害险 Term-Life&ADD身故给付 Death Benefit被保险人疾病身故，一次性支付保险金额。I
5、f the insured dies due to illness,a lump sum amount shall be payable.意外事故身故保险金 Accidental Death Benefit合同期内，若被保险人因意外事故在180天内死亡，按100%保险金额给付。In the case of death caused by accidents within 180 days,a lump sum amount shall be payable.意外事故残疾保险金 Accidental Disability Benefit 合同期内，若被保险人因意外事故导致残疾，按残疾程度给付保险
6、金额10%-100%的赔偿。详情请参照给付比例表。In the case of dismemberments caused by accidents,an amount equal to 10%-100%of the sum assured shall be payable.Please refer to the Schedule of Indemnities attached in product summary.团体定期寿险&意外伤害险 Term-Life&ADD员工 Employee保险责任Insurance Liability定期寿险Term-Life Insurance意外伤害险AD
7、&D Insurance保额 Sum Assured10万CNY 100,00036倍基本月薪36 times base monthly salary团体重大疾病保险 Dread Disease保险责任Insurance Liability重大疾病Dread Disease赔付比例Reimbursement Ratio保额 Sum AssuredCNY 50,000100%保险责任 Insurance Benefit 若被保险人自参加本附加合同之日起九十天后首次发病并经专科医生首次确诊患有任何一项包含在其选择的保障计划内的重大疾病，本公司将按约定的保险金额给付保险金予被保险人。给付后，本公司对
8、该被保险人的保险责任随即终止。If the Insured is diagnosed for the first time by a specialist as Dread Diseases set out in this Rider first incidence after 90 days from the Commencement Date of the Rider,the Company shall pay the Sum Assured specified in this Rider to the Insured.团体重大疾病保险 Dread Disease1、恶性肿瘤 Malign
9、ant tumor 2、急性心肌梗塞 AMI 3、脑中风后遗症 Stroke sequelae 4、终末期肾病（或称慢性肾功能衰竭尿毒症）Kidney failure 5、冠状动脉搭桥术（或称冠状动脉旁路移植术）Coronary artery bypass surgery(or coronary artery bypass grafting 6、重大器官移植术或造血干细胞移植术 Major organ transplantation or hematopoietic stem cells transplantation7、多个肢体缺失 Loss of limbs 8、急性或亚急性重症肝炎 Ac
10、ute or subacute severe hepatitis 9、脑炎后遗症或脑膜炎后遗症 Sequelae of meningitis or encephalitis 10、慢性肝功能衰竭失代偿期 Chronic liver failure decompensated 11、良性脑肿瘤 Benign brain tumors 12、深度昏迷 Deep coma 13、双耳失聪 Deafness 14、双目失明 Blindness 15、瘫痪 Paralyzed 16、心脏瓣膜手术 Heart valve surgery 17、严重阿尔茨海默病 Severe Alzheimers Dise
11、ase 18、严重脑损伤 Major head trauma 19、严重帕金森病 Severe Parkinsons disease 20、严重III度烧伤 Major burns 21、严重原发性肺动脉高压 Severe primary pulmonary arterial hypertension 22、严重运动神经元病 Serious motor neuron disease 23、语言能力丧失 Loss of speech 24、重型再生障碍贫血 Severe aplastic anemia 25、主动脉手术 Aortic Surgery 26、严重心肌病 Severe cardiom
12、yopathy 27、慢性肺功能衰竭 Chronic lung failure 28、严重多发性硬化症 Serious multiple sclerosis 29、严重溃疡性结肠炎 Severe ulcerative colitis30、严重系统性红斑狼疮性肾病 Severe systemic lupus erythematosus nephropathy医疗险Medical InsuranceCommercial Medical Insurance&Social Medical Insurance商业医疗保险与社会医疗保险员工医疗险计划Employee medical insurance p
13、lan年限额(每人/每年)Annual Limit(per capita/per year)门诊 Outpatient CNY 20,000住院 Inpatient医保范围内 赔付比例Reimbursement Ratio within the Social Medical Insurance scheme 门诊 Outpatient 90%*住院 Inpatient90%*医保范围外 赔付比例Reimbursement Ratio exceed the Social Medical Insurance schemeN/A是否必须使用医保卡Must Use Social Medical Ins
14、urance Card(Y/N)Y团体医疗保险 Group Medical Insurance Plan 特别约定门急诊医疗保险责任：保险期间内承担被保险因意外或疾病在嘉会国际医院嘉会诊所就诊所产生的医疗费用（不受社保限制）年限额1000元，无免赔额70%赔付。Special agreementoutpatientandemergencytreatment:hospitalizationcostsinJiahuiclinicwhenaccidentordiseaseiscoveredduringtheinsuranceperiodwithin30%copayandonethousandyuan
15、annuallimited员工Employee中华人民共和国境内社保指定二级（含）以上医保定点公立医院，武警医院、部队医院、职工医院需达三级。Public hospitals designated by Social Medical Scheme classified as Grade II or above are covered.Armed police hospitals,military hospitals or workers hospitals must be Grade III.可就诊的医院 Eligible Hospitals就诊开药量限制 Restriction of Pre
16、scription 最大药量规定 Maximum medicine quantity at one occurrence常见病 Common disease慢性病Chronic disease急诊开药Emergency出院带药或出差带药Takeaway7天/days14天/days3天/days14天/daysu对诊断明确、病情稳定的慢性病(因治疗需要需长期连续服用同一类药物以控制病情，如果停药，会加重患者病情，产生严重不良后果)，门诊用药可限1个月内用量（但上次门诊有两天以上余量，本次门诊不可重复续用相同药品）。u此处所指慢性病，仅包括：高血压、高脂血症、慢性肾功能不全（氮质血症期、尿毒症）
17、、糖尿病、冠心病、脑血管病、慢性肝炎、脑中风、肝硬化、结核病、精神病、癌症、甲亢、甲减、痛风、类风湿性关节炎、前列腺肥大疾病。For chronic disease with clear diagnosis in stable condition that need continuously taking the same kinds of medicine for a long time to control the disease,the medicine usage of outpatient visit could be for one month at maximum.If ther
18、e is more than 2 days usage left from last outpatient visit,the patient cannot use the same kind of medicine in the next outpatient visit.Chronic disease here only includes hypertension,heart disease,diabetes and other specific diseases designated by local mandatory Social Medical Scheme.索赔流程及注意事项 P
19、rocedure and Special Notes for Claims 索赔流程 Claim Procedure员工本人填写索赔申请，与索赔资料(发票等）一并投递至9楼前台保险理赔箱Employee fills out the claim application and submits it with relevant materials（invoice）to Medical Claim Box in 9F frontdesk or Jiajing Clinic.阳光服务专员上门收取索赔申请并进行初审Sunshine customer service personnel drop in t
20、o pick up the application materials and initial analysis资料齐全 complete materials阳光人寿处理相关理赔Sunshine insurance examine claims.15个工作日 15 working days阳光人寿将理赔结果通知被保险人Sunshine insurance inform you of the results.索赔资料递交 Claim Material Submission1.索赔前，请先填写索赔申请表。Before submission of claim,please fill out clai
21、m application form.2.将相关单据等装订在索赔申请表后投递至9楼前台或嘉静保险理赔箱。The relevant documents should be attached behind the claim application form to medical claim box in 9F Frontdesk or Jiajing Clinic.3.阳光人寿的服务专员将上门收取理赔资料（每月12号左右）。The on-site service staff of Sunshine insurance will collect the claim materials(every
22、12th).4.建议索赔时间 Suggestion of time bar for claim submission：医疗保险金的索赔建议门诊、住院费用在发生后的三个月内索赔；3 months for outpatient and inpatient expenses;医疗保险的索赔 Medical Insurance Claims门诊团险索赔申请表门诊病历复印件检查化验报告的复印件处方原件及药品清单原件收据或发票原件，若多方报销时需提供收据原件，或收据复印件（加盖第三方理赔章）及其它保险机构已赔付分割单原件其他本公司要求的证明材料若有必要，阳光人寿有权要求以上所有材料的原件若为急诊,应符合急
23、诊条件,并由医院加盖急诊章因意外伤害事故造成的门诊医疗，员工或员工家属需提供与确认意外伤害事故的性质、原因、伤害程度有关的证明材料Out-patient1.(OP&IP)Copy of Outpatient Medical reportCopy of check up report Original Prescription and medicine list 5.Original Receipts or Invoice6.Other proofs or materials required by the Company3.If necessary,Sunshine has the right
24、 to ask for originals for the above materials.4.If Emergency,shall be comply with the definition of Emergency with seal of Emergency in the Hospital5.In case of accident injury,materials for certifying the nature,cause and degree of injury are required医疗保险的索赔 Medical Insurance Claims住院团险索赔申请表住院病历报告复
25、印件住院小结复印件医院出具的诊断说明书复印件医疗费用收据或发票原件，若多方报销时需提供收据原件，或收据复印件（加盖第三方理赔章）及其它保险机构已赔付分割单原件住院费用明细原件，载明住院期间每日各项费用明细其他公司要求的证明材料若有必要，阳光人寿有权要求以上所有材料的原件因意外伤害事故造成的住院医疗，员工或员工家属需提供与确认意外伤害事故的性质、原因、伤害程度有关的证明材料In-patient1.(OP&IP)Copy of Inpatient Medical record Copy of In-patient summary4.Copy of Diagnosis report5.Origina
26、l receipts or Invoice 6.Original In-patient expense list Other proofs or materials required by the CompanyIf necessary,Sunshine has the right to ask for originals for the above materialsIn case of accident injury,materials for certifying the nature,cause and degree of injury are required索赔单据的要求 Requ
27、irements for Claim Materials 索赔时所提供的病历复印件必须符合以下标准：Thecopyofmedicalrecordshould:病历上清晰注明病情、检查、治疗、用药及剂量；Specifytheconditions,examination,treatment,prescriptionanddosage;病历上的记录与收据上的收费的项目相符；Includethesameexpenseitemsasthoseonthereceipts;病历上的诊病日期须与收据上的日期一致（特殊原因请用文字说明）。Havethesamevisitdatewiththatontherece
28、ipts(Anydifferencesshouldbeclarified).医疗卫生收费统一收据上应有医院收费章及财政专用章。Medicalreceiptsshouldbechoppedwiththehospitalandfiscalstamps.收据上的姓名无误。若有误或由于生僻字医院电脑无法打印的，请您告知医院更正或手写后加盖医院的更正章。Thenameonthereceiptshouldbecorrect.Shouldtherebeanydifference,pleaseaskthehospitalforacorrectionandchopwherechanged.关于发票的问题 Abo
29、ut Original Invoice 收据/发票或社保结算单遗失：Lost of original receipts or invoices:唯一有效的费用类索赔凭据，如不能提供收据或者结算单原件，将无法获得赔付。Onlyvalidcertificationsforclaim.Notreimbursablewithoutoriginalcopy.任何形式的收据遗失证明或者财务证明材料均无法代替收据原件作为索赔的有效材料。Anyformsofcertificationforthelostwillnotbeconsideredasvalidclaimmaterialsinsteadoforigi
30、nalcopy.Q&A特别留意 Special Attention 理理赔遭遇延、拒遭遇延、拒赔处理的原因通常有理的原因通常有 Common causes of claim rejection and delay:在非指定医院就诊Visit of non-designated hospitals缺少就诊病历、药品明细清单Lack of medical record or detailed expenses list无病症单纯配药Prescription without corresponding symptoms 检查、治疗、用药与所诊断疾病不符的Examination/treatment/m
31、edication inconsistent with the diagnosis非本人就诊（如他人代诊、代配药等）Hospital visit not by the insured发票名称与实际姓名不符The name recorded on the medical invoice not correct在医院药房以外的机构购药Medicines purchased in pharmacy outside the hospital产检费用在生育完成前递交Maternity expenses submitted before child delivery提供的单据或资料不齐、被涂改或内部有矛盾
32、Uncompleted documents/altered record/with contradiction within the claim materials违背诚实信用原则所发生的医疗费用Any dishonest behavior in claim to obtain reimbursementQ:我在嘉会接受治疗该如何理赔？有哪些项目不属于理赔范围？HowcanIgetclaimforcompensationfromJiahuiClinic?Whichitemsareoutoftheinsuredliability?A:必须使用员工折扣就诊，折扣后的医疗费用保险公司按照70%进行赔
33、付，赔付限额1000元。医疗美容、齿科治疗不属于理赔范围。Medicalcosmetologyanddentaltreatmentarenotcovered.Annualcompensationlimitis1000yuanwith30%copayafteryourdiscountfee.Q:每次开药有药量限制吗？IsthereanylimittoRestrictionofPrescription A:就诊开药量限制 RestrictionofPrescription最大药量规定 Maximum medicine quantity at one occurrence常见病 Common dis
34、ease慢性病Chronic disease急诊开药Emergency出院带药或出差带药Takeaway7天/days14天/days3天/days14天/daysQ:我如何知道哪些药品是能获得赔偿?哪些是自费的？HowdoIknowwhichdrugsareabletogetcompensationandwhichareattheirownexpense?A:为了保障您的保险权益，避免保险公司拒赔自费药,请您在就诊时可以告知医生因需要向保险公司索赔.避免使用自费类药品。Inordertoprotectyourrightsandinterestsoftheinsurance,theinsura
35、ncecompanyexclusionstoavoiddrugexpense,pleaseinformyourdoctorwhenyouseeadoctorbecauseyouneedtomakeaclaimtotheinsurancecompany.avoidtheuseofselffinanceddrugs.Q:如果我没有当地的医保卡,住院费用如何进行理赔?IfIdonthavealocalhealthinsurancecard,howtomakeaclaimforthecostofhospitalization?A:住院必须使用医保卡,若未使用医保卡，需事后进行医保结算。Medicare
36、cardmustbeusedinhospital,ifyoudonotuseMedicarecard,theneedforhealthinsurancesettlement.联系我们 Contacts您可以通过以下方式联系我们：You may contact us through following lines:嘉会医疗项目组Service Team 客户服务经理:郭晶晶 Customer Service manager Rachel Guo(8621)65867780Phone:13816655550Email:guojingjing- 对于投诉或咨询，被保险人1个工作日内获得合理解释，对于需要进一步调查的情形，将在3个工作日内给予答复。For complains or consultation,the insured will receive reasonable explanation within 1 working day.For further verification,it may take 3 working days.