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保险期间：2016年07月31日–2017年07月30日InsuredPeriod:FromJuly.31st2016toJuly.30st2017嘉会诊所保险福利宣讲会JIAHUICLINCEmployeeBenefitsInsuranceCommunication
1内容Contents阳光人寿简介SunshineInsuranceIntroduction保险福利及责任InsuranceBenefits&Liability索赔流程及注意事项ClaimProcedureandSpecialNotesQ&A1234
2阳光人寿简介SunshineInsuranceIntroduction
3阳光保险集团SunshineInsuranceGroup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家二级机构开业运营，三四级分支机构700余家。
4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。
5保险福利及责任InsuranceBenefits&Liability
6GroupInsuranceBenefitsOverview团体保险福利概览Term-LifeInsurance定期寿险Deathduetodisease疾病死亡AD&DInsurance意外伤害险Deathduetoaccident意外死亡Disabilityduetoaccident意外残疾DreadDisease重大疾病30kindsofCriticalillness30种重大疾病MedicalInsurance医疗保险Outpatient+Inpatient门急诊+住院
7非医疗险Non-MedicalInsurance
8团体定期寿险&意外伤害险Term-Life&ADD身故给付DeathBenefit被保险人疾病身故，一次性支付保险金额。Iftheinsureddiesduetoillness,alumpsumamountshallbepayable.意外事故身故保险金AccidentalDeathBenefit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。Inthecaseofdeathcausedbyaccidentswithin180days,alumpsumamountshallbepayable.意外事故残疾保险金AccidentalDisabilityBenefit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金额10%--100%的赔偿。详情请参照给付比例表。Inthecaseofdismembermentscausedbyaccidents,anamountequalto10%--100%ofthesumassuredshallbepayable.PleaserefertotheScheduleofIndemnitiesattachedinproductsummary.
9团体定期寿险&意外伤害险Term-Life&ADD员工Employee保险责任InsuranceLiability定期寿险Term-LifeInsurance意外伤害险AD&DInsurance保额SumAssured10万CNY100,00036倍基本月薪36timesbasemonthlysalary
10团体重大疾病保险DreadDisease保险责任InsuranceLiability重大疾病DreadDisease赔付比例ReimbursementRatio保额SumAssuredCNY50,000100%保险责任InsuranceBenefit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，本公司对该被保险人的保险责任随即终止。IftheInsuredisdiagnosedforthefirsttimebyaspecialistasDreadDiseasessetoutinthisRiderfirstincidenceafter90daysfromtheCommencementDateoftheRider,theCompanyshallpaytheSumAssuredspecifiedinthisRidertotheInsured.
11团体重大疾病保险DreadDisease1、恶性肿瘤Malignanttumor2、急性心肌梗塞AMI3、脑中风后遗症Strokesequelae4、终末期肾病（或称慢性肾功能衰竭尿毒症）Kidneyfailure5、冠状动脉搭桥术（或称冠状动脉旁路移植术）Coronaryarterybypasssurgery(orcoronaryarterybypassgrafting6、重大器官移植术或造血干细胞移植术Majororgantransplantationorhematopoieticstemcellstransplantation7、多个肢体缺失Lossoflimbs8、急性或亚急性重症肝炎Acuteorsubacuteseverehepatitis9、脑炎后遗症或脑膜炎后遗症Sequelaeofmeningitisorencephalitis10、慢性肝功能衰竭失代偿期Chronicliverfailuredecompensated11、良性脑肿瘤Benignbraintumors12、深度昏迷Deepcoma13、双耳失聪Deafness14、双目失明Blindness15、瘫痪Paralyzed16、心脏瓣膜手术Heartvalvesurgery17、严重阿尔茨海默病SevereAlzheimer'sDisease18、严重脑损伤Majorheadtrauma19、严重帕金森病SevereParkinson'sdisease20、严重III度烧伤Majorburns21、严重原发性肺动脉高压Severeprimarypulmonaryarterialhypertension22、严重运动神经元病Seriousmotorneurondisease23、语言能力丧失Lossofspeech24、重型再生障碍贫血Severeaplasticanemia25、主动脉手术AorticSurgery26、严重心肌病Severecardiomyopathy27、慢性肺功能衰竭Chroniclungfailure28、严重多发性硬化症Seriousmultiplesclerosis29、严重溃疡性结肠炎Severeulcerativecolitis30、严重系统性红斑狼疮性肾病Severesystemiclupuserythematosusnephropathy
12医疗险MedicalInsurance
13CommercialMedicalInsurance&SocialMedicalInsurance商业医疗保险与社会医疗保险
14员工医疗险计划Employeemedicalinsuranceplan年限额(每人/每年)AnnualLimit(percapita/peryear)门诊OutpatientCNY20,000住院Inpatient医保范围内赔付比例ReimbursementRatiowithintheSocialMedicalInsurancescheme门诊Outpatient90%*住院Inpatient90%*医保范围外赔付比例ReimbursementRatioexceedtheSocialMedicalInsuranceschemeN/A是否必须使用医保卡MustUseSocialMedicalInsuranceCard(Y/N)Y团体医疗保险GroupMedicalInsurancePlan★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。★Specialagreementoutpatient and emergency treatment:hospitalization costs in Jiahui clinic when accident or disease is covered during the insurance period within 30% copay and one thousand yuan annual limited
15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。PublichospitalsdesignatedbySocialMedicalSchemeclassifiedasGradeIIorabovearecovered.Armedpolicehospitals,militaryhospitalsorworker'shospitalsmustbeGradeIII.可就诊的医院EligibleHospitals
16就诊开药量限制RestrictionofPrescription最大药量规定Maximummedicinequantityatoneoccurrence常见病Commondisease慢性病Chronicdisease急诊开药Emergency出院带药或出差带药Takeaway7天/days14天/days3天/days14天/days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）。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）、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。Forchronicdiseasewithcleardiagnosisinstableconditionthatneedcontinuouslytakingthesamekindsofmedicineforalongtimetocontrolthedisease,themedicineusageofoutpatientvisitcouldbeforonemonthatmaximum.Ifthereismorethan2days’usageleftfromlastoutpatientvisit,thepatientcannotusethesamekindofmedicineinthenextoutpatientvisit.Chronicdiseasehereonlyincludeshypertension,heartdisease,diabetesandotherspecificdiseasesdesignatedbylocalmandatorySocialMedicalScheme.
17索赔流程及注意事项ProcedureandSpecialNotesforClaims
18索赔流程ClaimProcedure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Employeefillsouttheclaimapplicationandsubmitsitwithrelevantmaterials（invoice）toMedicalClaimBoxin9FfrontdeskorJiajingClinic.阳光服务专员上门收取索赔申请并进行初审Sunshinecustomerservicepersonneldropintopickuptheapplicationmaterialsandinitialanalysis资料齐全completematerials阳光人寿处理相关理赔Sunshineinsuranceexamineclaims.15个工作日15workingdays阳光人寿将理赔结果通知被保险人Sunshineinsuranceinformyouoftheresults.
19索赔资料递交ClaimMaterialSubmission1.索赔前，请先填写索赔申请表。Beforesubmissionofclaim,pleasefilloutclaimapplicationform.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。Therelevantdocumentsshouldbeattachedbehindtheclaimapplicationformtomedicalclaimboxin9FFrontdeskorJiajingClinic.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）。Theon-siteservicestaffofSunshineinsurancewillcollecttheclaimmaterials(every12th).4.建议索赔时间Suggestionoftimebarforclaimsubmission：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；3monthsforoutpatientandinpatientexpenses;
20医疗保险的索赔MedicalInsuranceClaims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)CopyofOutpatientMedicalreportCopyofcheckupreportOriginalPrescriptionandmedicinelist5.OriginalReceiptsorInvoice6.OtherproofsormaterialsrequiredbytheCompanyIfnecessary,Sunshinehastherighttoaskfororiginalsfortheabovematerials.IfEmergency,shallbecomplywiththedefinitionofEmergencywithsealofEmergencyintheHospitalIncaseofaccidentinjury,materialsforcertifyingthenature,causeanddegreeofinjuryarerequired
21医疗保险的索赔MedicalInsuranceClaims住院《团险索赔申请表》住院病历报告复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)CopyofInpatientMedicalrecordCopyofIn-patientsummary4.CopyofDiagnosisreport5.OriginalreceiptsorInvoice6.OriginalIn-patientexpenselistOtherproofsormaterialsrequiredbytheCompanyIfnecessary,SunshinehastherighttoaskfororiginalsfortheabovematerialsIncaseofaccidentinjury,materialsforcertifyingthenature,causeanddegreeofinjuryarerequired
22索赔单据的要求RequirementsforClaimMaterials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）。Havethesamevisitdatewiththatonthereceipts(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.
23关于发票的问题AboutOriginalInvoice收据/发票或社保结算单遗失：Lostoforiginalreceiptsorinvoices: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。Anyformsofcertificationforthelostwillnotbeconsideredasvalidclaimmaterialsinsteadoforiginalcopy.
24Q&A
25特别留意SpecialAttention理赔遭遇延、拒赔处理的原因通常有Commoncausesofclaimrejectionanddelay:在非指定医院就诊Visitofnon-designatedhospitals缺少就诊病历、药品明细清单Lackofmedicalrecordordetailedexpenseslist无病症单纯配药Prescriptionwithoutcorrespondingsymptoms检查、治疗、用药与所诊断疾病不符的Examination/treatment/medicationinconsistentwiththediagnosis非本人就诊（如他人代诊、代配药等）Hospitalvisitnotbytheinsured发票名称与实际姓名不符Thenamerecordedonthemedicalinvoicenotcorrect在医院药房以外的机构购药Medicinespurchasedinpharmacyoutsidethehospital产检费用在生育完成前递交Maternityexpensessubmittedbeforechilddelivery提供的单据或资料不齐、被涂改或内部有矛盾Uncompleteddocuments/alteredrecord/withcontradictionwithintheclaimmaterials违背诚实信用原则所发生的医疗费用Anydishonestbehaviorinclaimtoobtainreimbursement
26Q: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.
27Q:每次开药有药量限制吗？IsthereanylimittoRestrictionofPrescriptionA:就诊开药量限制RestrictionofPrescription最大药量规定Maximummedicinequantityatoneoccurrence常见病Commondisease慢性病Chronicdisease急诊开药Emergency出院带药或出差带药Takeaway7天/days14天/days3天/days14天/days
28Q: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,theinsurancecompanyexclusionstoavoiddrugexpense,pleaseinformyourdoctorwhenyouseeadoctorbecauseyouneedtomakeaclaimtotheinsurancecompany.avoidtheuseofselffinanceddrugs.
29Q:如果我没有当地的医保卡,住院费用如何进行理赔?IfIdon'thavealocalhealthinsurancecard,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。Medicarecardmustbeusedinhospital,ifyoudonotuseMedicarecard,theneedforhealthinsurancesettlement.
30联系我们Contacts您可以通过以下方式联系我们：Youmaycontactusthroughfollowinglines:嘉会医疗项目组ServiceTeam客户服务经理:郭晶晶CustomerServicemanagerRachelGuo(8621)–65867780Phone:13816655550Email:guojingjing-lsh@sinosig.com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。Forcomplainsorconsultation,theinsuredwillreceivereasonableexplanationwithin1workingday.Forfurtherverification,itmaytake3workingdays.
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