aia employee medical benefits 1 sep 2009 - 30 aug 2010 ... indian international school singapore...

AIA confidential and proprietary information. Not for distribution. 11

AIA Employee Medical Benefits

1 Sep 2009 - 30 Aug 2010

Global Indian International School SingaporePrepared by:HEMA SHETTY & JOE LIAN

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AIA confidential and proprietary information. Not for distribution.

1. Group Hospital & Surgical Benefits

Covers inpatient hospital confined treatments

2. Extended Major Medical Benefits Reimbursement for extended hospital stay, complimenting Group Hospital & Surgical Benefits

3. Mediguard Clinical Outpatient Benefits

4. Specialists Clinical OutpatientBenefits

Covers clinical outpatient consultation with Panel & Non-Panel General Practitioner

Covers clinical outpatient consultation and diagnostic tests at Specialists Clinic

GIIS - Insurance Coverage

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AIA confidential and proprietary information. Not for distribution. AIA confidential and proprietary information. Not for distribution. 3

1. Group Hospital & Surgical Benefits (1 of 10) – Ward Charges

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1. Group Hospital & Surgical Benefits (2 of 10)

Coverage

Yr: 2008-09 Yr: 2009-10

Daily Room & Board (Up to 120 days per disability) S$ 230 S$ 230

Intensive Care Unit (Up to 30 days per disability) S$ 690 S$ 690

Hospital Miscellaneous (drugs & medicines, facilities use) Services S$ 2,200 S$ 3,000

Surgical fees (Surgeons fees for operation performed) S$ 2,800 S$ 4,000

In-hospital doctor’s consultation (1 visit per day up to 120 days) S$ 40 S$ 60

Accidental Miscarriage (as per disability, includes ectopic pregnancy) Within limit Within limit

Emergency Outpatient treatment (due to accident) S$ 1,500 S$ 1,500

Pre- & Post-hospitalisation specialist consultation (90 days limit) S$ 500 S$ 1,000

Hospitalisation in Singapore Restructured or Government Hospital(within room & board limits)

S$ 11,500 S$ 11,500

Overseas Hospitalisation due to Accident 150% of GHS 150% of GHS

Outpatient Kidney Dialysis/Cancer Treatment S$5,000 S$10,000

Claim Eligibility:a) Minimum confinement of 6 hours required in the hospitalb) One to another similar disability should be separated by 30 days to avail all benefits afresh

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Benefits

1(a) Daily Room & Board BenefitA Daily Room & Board Benefit shall be paid when, Upon recommendation of a Registered Medical Practitioner, an insured Member is registered as a bed patient in a Hospital. The amount of the said benefit shall be equal to the actual charges made by the Hospital during the Insured Member's confinement, but in no event shall the benefit under this Paragraph exceed for any one day the rate of Daily Room & Board Benefit set forth in the Policy Schedule or exceed the number of days as specified in the same Schedule.


1(b) Intensive Care UnitThe Company shall pay the actual Room & Board charges incurred by the insured Member while confined in an intensive Care Unit (ICU) in the Hospital, subject to a maximum number of days and the amount shall not exceed the ICU amount set forth in the Policy Schedule.

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2. Other Hospital Services

If an insured Member is entitled to benefits payable under Paragraph 1 of this Section, the Insurance Company(AIA) shall also pay the amount actually charged by the Hospital for any of the following services rendered during such Hospital confinement which are customarily supplied by the Hospital but the amount shall not exceed in aggregate the Other Hospital Services amount set forth in the Policy Schedule


• Administration of Blood Plasma, but not the cost of Blood or Blood Plasma

• Ambulance Services to and / or from the Hospital not to exceed for any trip the rate of the Daily Room & Board benefit

• Anesthesia and oxygen and their administration, including anesthetists fee

• Basal Metabolism Tests• Dressings Ordinary Splints and Plaster Casts• Drugs and Medicine consumed on premises• Electrocardiograms• Intravenous infusion• Laboratory Examinations• Physical Therapy• Use of Operation Room• X-ray Examinations• Implants

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3. Surgical Benefit

A surgical benefit shall be paid in an amount equal to the actual charges made for such operation performed by one or more Registered Medical Practitioners, including any assistant surgeons, provided however that the maximum benefit for all surgical operations performed for Any One Disability shall not exceed the Maximum Surgical Benefit shown in the Policy Schedule and each operation is subject to the amount obtained by multiplying the appropriate percentage shown for that operation in the Surgical Schedule of Fees[v1] by the maximum Surgical Benefit shown in the Policy Schedule. If two or more surgical procedures are performed through a single incision reimbursement for expenses for all such procedures shall not exceed the amount indicated for the one surgical procedure performed for which the largest amount is payable.

4. In-Hospital Doctor's ConsultationConsultation fees charged by Registered Medical Practitioners while an insured Member was hospitalized shall be paid in an amount equal to the actual charges made for consultation provided however that the maximum daily benefit shall not exceed the maximum In-Hospital Doctor Consultant Benefit shown in the Policy Schedule. For the Benefit only one visit per day shall be covered and the benefit is further limited to the number of days as specified in the Policy Schedule.


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5. Emergency Out-Patient Treatment (Accident)If as a result of an accident and within twenty-four (24) hours following such an accident an Insured Member shall require emergency out-patient treatment in the Out-Patient Department of a Hospital or at a Registered Medical Practitioner's office and follow-up treatment within thirty-one (31) days thereafter, the Company shall pay the actual charges made but not to exceed the maximum Emergency Out-Patient Treatment Benefit set forth in the Policy Schedule. The maximum benefit shall be included in the total of the maximum Other Hospital Services Benefit.

6. Pre-& Post Hospitalization Specialities Consultation, Diagnostic X-ray and Laboratory TestThe Insurance Company (AIA) shall pay the amount of charges made for specialist’s consultation, diagnostic x-ray and laboratory examination which are recommended by a Registered Medical Practitioner and incurred in the period commencing thirty-one (31) days before and ending ninety (90) days after hospitalization or surgery, but not to exceed the maximum benefit in the Policy Schedule.

7. Hospitalization in Singapore Government Hospital or Singapore Government Restructured HospitalIf an insured Member is hospitalized in a Singapore Government or Singapore Government Restructured Hospital (except National University Hospital) while staying in a Class where the Daily Room & Board charges shall not exceed the Daily Room & Board Benefit set forth in the Policy Schedule, individual limits of item (2) to (6) as set forth in the Policy Schedule shall not apply and the actual charges made for the hospitalization shall be paid subject to the Overall Maximum Limit Per Disability shown in the Policy Schedule.


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8. Overseas Hospitalization (Accident)If an insured member sustains injury from an accident while traveling outside of Singapore & as a result

of such injury requires hospitalization overseas, the company shall pay for the actual medical expenses incurred for such hospitalization, up to a increased maximum benefit limit equivalent to 1.5 times of the maximum benefit limits applicable to items 1 to 4 as shown in the Policy Schedule. Coverage shall apply to travel within 180 days of departure from Singapore.This benefit is applies to Insured Members who reside & work in Singapore.

9. Death BenefitUpon receipt of due proof of death of any Insured Member in the form-required by the Company, an

amount determined in accordance with the Policy Schedule shall be payable to the Policyholder.10.Outpatient Kidney Dialysis/Cancer TreatmentThis benefit applies only if the coverage has been applied for by the Policyholder & the Benefit limit is

shown on the policy schedule.If an insured member shall necessary incurred outpatient expenses for the following treatments, the

Company shall reimburse for such medical expences up to the maximum benefit as stated in the Policy Schedule.


a) Kidney dialysis as recommended by a Registered Medical Practitioner.b) Cancer treatment by a Registered Medical Practitioner. Cancer shall mean a focal autonomous new

growth of tissue that has no useful function & the new growth has the characteristics of marginal invasion, relentless growth or distant spread with a lethal effect. Such cancer must be positively diagnosed by a Registered Medical Practitioner who is also a certified Pathologist, upon the basis of a Microscopic Examination of fix tissues, or preparations from the Hemic System. Such diagnosis shall be based solely on the accepted criteria of malignancy after a study of the histocytologic architecture or pattern of the suspect tumour, tissue or specimen. Clinical diagnosis does not meet this standard.

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LIMITATION & EXCLUSIONS & CLAIM PROCEDURES

Reasonable & Customary Charges

No benefit shall be paid for charges specified under Section B which are in excess of the general level of charges being made by other providers of similar standing in the locality where the charges are incurred, when providing like or comparable treatment, services or supplies for a similar Sickness or Injury.

Limitation

When an insured Member is entitled to benefits payable under the Employee's Compensation legislation, any government or public programme of medical benefits, or other group or individual insurance, the benefits payable under this Policy shall be limited to the balance of expenses not covered by benefits payable under such legislation, programme or other insurance, or that computed in accordance with the Policy Schedule of this Policy, whichever is less.


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Exclusions

No benefit shall be payable under this Policy for any one of the following occurrences:


• Pre-existing conditions which have existed during the twelve (12) months preceding the Entry Date of the Insured Member, whetherknown or unknown to the insured Member in so far as the cause and pathology of the conditions have already existed, unless the Insured Member affected by these conditions has been insured under this Policy continuously for twelve (12) months.

• Investigation and treatment of Psychological, emotional and mental conditions; alcoholism or drug addiction; intentional self-inflicted injuries, or injuries sustained as a result of a criminal act of the Insured Member.

• Injuries arising from direct participation in a strike, riot, insurrection or war, declared or undeclared. • General physical or medical check-up or tests net incidental to treatment or diagnosis of an actual Sickness or Injury or any treatment

which is not medically necessary or treatment of an optional nature; treatment with respect to weight mgmt, immunization, vaccination or inoculation; non-prescribed medication.

• Procurement or use of special braces, any appliances, any equipment or prosthetic devices, any implants, contact lenses, eye glasses, hearing aids or the fitting of the same and non-medical services such as television, telephone and the like.

• Any dental & treatment or surgery except if procedure is necessitated by damage to sound natural teeth as a result of an injury occurring during the period of insurance, any eye examination/treatment or surgical procedure for correction of eye refraction including myopia, cosmetic or plastic surgery/treatment for purposes of beautification and any complications arising thereof.

• Any investigation, treatment or surgical operation for congential anomalies or physical defects present at and existing from the time of birth regardless of the time of discovery or the time of such treatment or surgical treatment.

• Birth control measures, treatment pertaining to infertility, treatment occasioned by or resulting from pregnancy, childbirth, abortion, except ectopic pregnancy and non-elective miscarriage due to medical reason; treatment or surgical procedures required or recommended subsequent to consultations at Fertility clinics, In-Vitro Fertilisation clinics, Reproductive assistance clinics or centres, clinics or centres for Reproductive Medicine.

• Acupuncture, acupressure, bonesetting, herbalist treatment, hypnotism, massage therapy, aroma therapy, & other forms of alternative treatments, treatments by podiatrist, chiropractors & traditional Chinese medicine practitioners.

• Educational treatments such as speech therapy, diabetic classes & nutritional treatments or group support treatments.• Special or pvt duty nursing care; clinical home care; custodial care in any setting; day care; hospice; respite care.• Acquired Immune-Deficiency Syndrome (AIDS) or any HIV. For the purpose of this Policy:

a. The definition of AIDS shall be that used by the World Health Organization in 1987, or any subsequent revision by the World Health Organization of that definition; andb. Infection by HIV shall be deemed to have occurred where blood tests indicate in the opinion of the Company either the presence of any HIV or antibodies to such virus.

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Partial list, sample only

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2. Extended Major Medical Benefits

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3. Mediguard Clinical Outpatient

This plan pays for the clinical outpatient consultation, medical fees, basic outpatient lab test, etc. on a visit to a general practitioner under panel & non-panel

Coverage

Benefits

AIA Panel Full reimbursement, upon producing mediguard cardAIA Non-panel

• Reimbursement up to SGD 20 for visit to non-panel GP per day

• Govt. polyclinic full reimbursement• Overseas reimbursement up to SGD 20• A&E dept. of S’pore hosp. SGD 70, up to 2 visits per policy

year

Note: Co-payment of SGD 5 applies

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4. Specialists Clinical Outpatient Benefits

This plan pays for the specialists clinical outpatient consultation, diagnostic x-ray & lab test, etc on a visit to a specialists clinic

Coverage

BenefitsBenefits per policy yearSpecialists Consultation

(Pediatrician Direct Access without referral letter / Max. of 3 visits per policy year upto 10% of specialists consultation –where applicable for dependent child coverage)

SGD 500

SGD 50 per visit

Diagnostic X-Ray & Lab Test SGD 500

Need a referral letter from general practitioner before visiting a specialist

Note:• Claims should be submitted within 20 days• Co-payment of SGD 20 per visit to specialists clinic.

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1. AIA Medical Claim Procedure

1. Group Hospital & Surgical Benefits

Covers inpatient hospital confined treatments. Extended Major Medical Benefits provides reimbursement for extended hospital stay

2. Mediguard Clinical Outpatient Covers clinical outpatient consultation with a General Practitioner

3. Specialist Payment Outpatient General Practitioner Referral Required3 Paediatric Clinic visits per policy year without GP referral letter

Claim Type and Claim Process

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1. AIA Medical Claim Procedure – Group Hospital & Surgical / EMM (1 of 2)

^ Provide bank account number to receive claim payment directly

Deposit advance to the hospital at the time of admission*

Submit the original invoices when seeking reimbursement

Claim assessment based on final invoice and other original receipts of payments made during the hospital stay

While getting discharged, request for the discharge summary & doctor’s report #

#Ask for doctor’s report (as per Part III of claim form) for claim above $1,000 in S’pore Govt. Hospitals and any amount of claim in pvt. Hospitals. Doctor’s report may cost $80 plus.Minimum confinement of 6 hours required in the hospitalday surgery payable under the group hospital and surgical benefits

Submit claim within 20 days of discharge

* NoteSingaporean & PR can make use of Medisave account for the deposit. Foreigner make deposit in cash.You may use Express claim process (ECP) form in the participating Hospitals (refer 2 of 2 attachment)If the above options are not used, make payment first and seek reimbursementIf ECP is unsuccessful, claimant has to reimburse the hospital or AIA, depending on claim status

AIA’s claim dept. will take 14 working days to process the claim, subject to completeness of all documents^

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1. Express Claim Process - ECP (2 of 2)

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2. AIA Medical Claim Procedure – Group Outpatient General Practitioner


Present the mediguard card to the panel clinic to avail cashless clinic visit*

Make Co-payment at the time of collecting the receipt / medicine

Make sure to present mediguard card at panel clinic to avoid claim rejection

Daily cap of $20 applies for non-panel clinic visits

Note*Unlimited visits allowed per policy year to AIA panel clinicsVisit to non-panel GP limited to $20 per visit per day2 visits per policy year is allowed for visit to Accident & Emergency department in Singapore up to $70 reimbursement Overseas clinic visit is capped at $20 per visit per day$5 co-payment applies under all above visits

Submit claim within 20 days of clinic visit


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3. AIA Medical Claim Procedure – Group Outpatient Specialists

Seek GP referral letter for visit to Specialists Clinic (referral letter is valid for 6 months)*

Retain all original receipts and doctor’s prescription plus copy of GP referral letter for submission to AIA

Co-payment of $20 applies per visit to the specialists clinics

Note*• Make co-payment of $20 at specialist clinic, per visit• Specialists clinic visit has a limit of $500 each for

specialist consultation & diagnostic tests per policy year• 3 visits to Paediatric clinic per policy year up to 10% of

the specialist outpatient consultation, without GP referral letter

• Paediatrician direct access forms part of the specialist consultation (where applicable)

Submit claim within 20 days of clinic visit



aia employee medical benefits 1 sep 2009 - 30 aug 2010 ... indian international school singapore...

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