This provides you with an extensive coverage over acute medical conditions that might otherwise be excluded from other basic insurance policies due to the following reasons:
- Basic Health Insurance policies do not provide coverage against major illnesses, diseases and critical medical conditions
- Insurance policies that are not upgraded as they gradually mature increase the probability of the holder not getting the essential coverage he or she needs
- Even with a high coverage, escalating medical costs can restrict your present benefits coverage, especially in the event of a critical medical condition requiring major surgery.
With these factors in mind, B-Health Major provides you with the protection and assurance you need by covering medical expenses that are not payable or insufficient under existing basic policies
- Comprehensive Cover
- Full Reimbursement up to the Overall Annual Limit
- A choice of deductible limits - as a policyholder, you have the freedom of determining the amount you want the basic policy to cover. You can also choose a plan that will cover expenses over and above your deductible limit, in the event that you decide to pay for medical fees personally
- Extensive coverage of major medical conditions as opposed to the limited list of medical benefits typically provided by employers
- Outpatient Treatments - Actual charges are reimbursed subject to benefit limits for outpatient cancer or kidney dialysis and emergency accidental injuries at clinics including dental treatment
B-Health Major Individual Plans
|SCHEDULE OF BENEFITS||M1||M2||M3||M4||M5|
|Hospital Room & Board||400||300||200||100||80|
|Intensive Care Unit||Full Reimbursement|
|Operating Theatre||Full Reimbursement|
|Hospital Services & Supplies||Full Reimbursement|
|PROFESSIONAL FEES & SERVICES|
|Pre-Hospital Diagnostic Test (within 31 days preceding confinement)||Full Reimbursement|
|Pre-Hospital Specialist consultation (within 31 days preceding confinement)||Full Reimbursement|
|Surgeon Fee||Full Reimbursement|
|Anaesthetist Fee||Full Reimbursement|
|In-Hospital Physician's Visit
(1 visit per day)
|Post Hospitalisation Treatment
(for Non-Surgical within 31 days from discharge)
|Ambulance Fee||Full Reimbursement|
|Emergency Accidental Outpatient Treatment
(within 24 hours and follow-up treatment up to 31 days)
|Emergency Accidental Dental Treatment
(within 24 hours and follow-up treatment up to 14 days)
|Home Nursing Care
(up to 60 days)
|Annual Outpatient Cancer or Kidney Dialysis Treatment||50,000||40,000||30,000||20,000||15,000|
(once per lifetime)
|Outpatient Physiotherapy Treatment
(within 90 days from discharge)
|DEDUCTIBLE PER DISABILITY||10,000||8,000||6,000||4,000||3,000|
|OVERALL ANNUAL LIMIT||100,000||80,000||60,000||40,000||30,000|
Annual Premium On Next Birthday (RM)
|1 - 17 years||180||160||140||120||100|
|18 - 35 years||360||330||290||260||220|
|36 - 45 years||480||420||350||320||270|
|46 - 55 years||575||480||400||370||320|
|56 - 70 years (Renewal Only)||1,200||890||650||520||460|
The amount payable will not exceed the actual costs of the services and the maximum liability of the company shall not exceed the limits of eligible expenses based on the Reasonable and Customary and Medically Necessary charges incurred less deductible for the account of the Insured.
HOSPITAL ROOM AND BOARD
Daily Charges for room and board and meals during confinement as a bedpatient.
INTENSIVE CARE UNIT
Daily charges as a bedpatient in the Intensive Care Unit of the hospital.
Charges for operating theatre incidental to the surgical procedure.
HOSPITAL SERVICES & SUPPLIES
Charges during confinement which shall include general nursing, prescribed medicines, dressing, X-rays, laboratory examinations, electrocardiograms, physiotherapy, administration of blood and blood plasma but excluding the cost of blood and plasma.
PRE-HOSPITAL DIAGNOSTIC TESTS
Charges for diagnostic tests which are recommended by a general practitioner within 31 days preceding hospital confinement. No payment shall be made if upon such diagnosis, the Insured does not result in hospital confinement for the treatment of the medical condition so diagnosed. Medications and consultation charged by the general practitioner will not be payable.
PRE- HOSPITAL SPECIALIST CONSULTATION
Fees charged by the Specialist which are recommended by a general practitioner in writing within 31 days preceding hospital confinement. Payment will not be made for clinical treatment (including medications and subsequent consultation) or where the Insured does not result in hospital confinement for the treatment of the medical condition so diagnosed.
Surgical fees and normal pre and post-operative care up to 31 days inclusive both before and after the operation.
Fees charged by the Anaesthetist for the supply and administration of anaesthesia.
IN-HOSPITAL PHYSICIAN'S VISIT
Fees charged by the Physician for the treatment of the Insured Person when confined for a non-surgical disability.
Charges for treatment within 31 days following discharge from hospital for a non-surgical confinement administered by the same Physician.
Charges for ambulance services for transporting the Insured Person to and from hospital. Payment is not made if the Insured Person is not hospitalised.
EMERGENCY ACCIDENTAL OUTPATIENT TREATMENT
Charges by the hospital or clinic in connection with the emergency treatment of bodily injury arising from an accident and received as an outpatient within 24 hours of the accident. Follow-up treatment is up to 31 days by the same Physician.
EMERGENCY ACCIDENTAL DENTAL TREATMENT
Fees charged for the treatment of accidental injuries to sound natural teeth within 24 hours of the accident. Follow-up treatment is up to 14 days by the same dentist.
HOME NURSING CARE
Daily charges for the services of licensed and qualified nurse in the Insured’s home for the continued treatment of the specific medical condition for which he/she was hospitalised. Such services must be recommended by the attending Physician.
ANNUAL OUTPATIENT CANCER OR KIDNEY DIALYSIS TREATMENT
If an Insured is diagnosed with the Cancer of Kidney Failure as defined below, the Company will reimburse the Reasonable and Customary Charges incurred for the Medically Necessary treatment performed at a legally registered cancer treatment center or at registered dialysis center subject to the limit of this disability as specified in the Schedule of Benefits.
Such treatment (radiotherapy or chemotherapy or dialysis excluding consultation, examination tests, take home drugs) must be received at the out-patient department of a Hospital or a registered cancer/dialysis treatment centre immediately following discharge from Hospital confinement or surgery.
Cancer is defined as the uncontrollable growth and spread of malignant cells and the invasion and destruction of normal tissue for which major interventionist treatment or surgery (excluding endoscopic procedures alone) is considered necessary. The cancer must be confirmed by histological evidence of malignancy. The following conditions are excluded:
|a.||Carcinoma in situ including of the cervix;|
|b.||Ductal Carcinoma in situ of the breast;|
|c.||Papillary Carcinoma of the bladder & Stage 1 Prostate Cancer;|
|d.||All skin cancers except malignant melanoma;|
|e.||Stage 1 Hodgkin's disease;|
|f.||Tumours manifesting as complications of AIDS.|
Kidney Failure means end stage renal failure presenting as chronic, irreversible failure of both kidneys to function as a result of which renal dialysis is initiated.
It is a specific condition of this Benefit that notwithstanding the exclusion of pre-existing conditions, this Benefit will not be payable for any Insured who had been diagnosed as a cancer patient and/or is receiving cancer treatment and/or has developed chronic renal diseases and/or is receiving dialysis treatment prior to the effective date of insurance.
Medical charges and professional fees for the surgical transplantation of the kidney, heart, lung, liver or bone marrow performed in a hospital. Payment is limited to one event per lifetime.
OUTPATIENT PHYSIOTHERAPY TREATMENT
Charges for outpatient physiotherapy treatment which is recommended in writing by the attending Physician within 90 days after discharge from hospital.
OVERALL ANNUAL LIMIT
Benefits payable in respect of expenses incurred for treatment provided to the Insured Person during the period of insurance shall be limited to Overall Annual Limit as stated in the Schedule of Benefits irrespective of a type/types of disability.
This shall mean the maximum annual reimbursement for benefits after deducting the greater of the following:
|a.||Deductible Per Disability specified in the Schedule of Benefit, OR|
|b.||Amounts paid by any other insurance policy for the same benefits.|
In the event the Overall Annual Limit having been paid, all insurance for the Insured Person hereunder shall immediately cease to be payable for the remaining policy year.
The total amount of reimbursement an Insured Person can receive in his/her lifetime is subject to the limit as set forth in the Schedule of Benefit in accordance to the plan insured. Once the limit is reached, the policy cover will automatically cease and cannot be renewed any further.
For detailed descriptions of the covered benefits, please refer to the Policy Contract.
PRE-EXISTING ILLNESS shall mean:
Disabilities that existed before the Effective date of Insurance that the Insured Person has reasonable knowledge of. An Insured Person may be considered to have reasonable knowledge of a pre-existing condition where the condition is one for which:
|a.||the Insured Person had received or is receiving treatment;|
|b.||medical advice, diagnosis, care or treatment has been recommended;|
|c.||clear and distinct symptoms are or were evident; or|
|d.||its existence would have been apparent to a reasonable person in the circumstances.|
SPECIFIED ILLNESSES shall mean the following disabilities and its related complications occurring within the first 120 days of Insurance of the Insured Person:
|a.||Hypertension, diabetes mellitus and Cardiovascular Disease|
|b.||All tumours, cancers, cysts, nodules, polyps, stones of the urinary system and biliary system.|
|c.||All ear, nose (including sinuses) and throat conditions|
|d.||Hernias, haemorrhoids, fistulae, hydrocele, varicocele|
|e.||Endometriosis including disease of the Reproductive System|
|f.||Vertebro-spinal disorders (including disc) and knee conditions|
Eligibility for benefits starts 30 days after the Insured has been included in the Policy, except for a covered Accident occurring after the effective date of coverage.
The Policy shall not cover:
- Pre-existing illness.
- Specified Illnesses occurring during the first 120 days of continuous cover.
- Any medical or physical conditions arising within the first 30 days of the Insured Person’s cover or date reinstatement whichever is latest except for accidental injuries.
- Care/treatment for which payment is not required or to the extent which is payable by any other insurance/indemnity covering the Insured and disabilities arising out of duties of employment or profession that is covered under a Workman’s Compensation Insurance Contract.
- Plastic/Cosmetic surgery, circumcision, eye examination, glasses and refraction or surgical correction of nearsightedness (Radial Keratotomy or Lasik) and the use or acquisition of prosthetic appliances or devices such as artificial limbs, hearing aids, implanted pacemakers and prescriptions thereof.
- Dental conditions including dental treatment or oral surgery except as necessitated by Accidental Injuries to sound natural teeth occurring wholly during the Period of Insurance.
- Private nursing, rest cures or sanitaria care, illegal drugs, intoxication, sterilisation, venereal disease and its sequelae, AIDS or ARC and HIV related diseases, any communicable diseases requiring quarantine by law.
- Any treatment or surgical operation for congenital abnormalities / deformities including hereditary conditions.
- Pregnancy, child birth (including surgical delivery), miscarriage, abortion and prenatal or postnatal care and surgical, mechanical or chemical contraceptive methods of birth control or treatment pertaining to infertility. Erectile dysfunction and tests or treatment related to impotence or sterilisation.
- Psychotic, mental or nervous disorders (including any neuroses and their physiological or psychosomatic manifestations).
- Hospitalisation primarily for investigatory purposes, diagnosis, x-ray examination, general physical or medical examinations not incidental to treatment or diagnosis of a Covered Disability or any treatment which is not Medically Necessary and any preventive treatments, preventive medicines or examinations carried out by a Physician, and treatments specifically for weight reduction or gain.
- Costs/expenses of services of a non-medical nature such as television, telephones, telex services, radios or similar facilities, admission kit/pack and other ineligible non-medical items.
- Sickness or injury arising from racing of any kind (except foot racing), hazardous sports such as but not limited to skydiving, water-skiing, underwater activities requiring breathing apparatus, winter sports, professional sports and illegal activities.
- Suicide, attempted suicide or intentionally self-inflicted injury while sane or insane.
- Private flying other than as a fare-paying passenger in any commercial scheduled airlines licensed to carry passengers over established routes.
- War or act of war, declared or undeclared, criminal or terrorist activities, active duty in any armed forces, direct participation in strikes, riots and civil commotion or insurrection.
- Ionising radiation or contamination by radioactivity from any nuclear fuel or nuclear waste from process of nuclear fission or from any nuclear weapons material.
- Expenses incurred for donation of any body organ by an Insured Person and costs of acquisition of the organ including all costs incurred by the donor during organ transplant and its complications.
- Expenses incurred for sex changes.
- Investigation and treatment of sleep and snoring disorders, and hormone replacement therapy and alternative therapy such as treatment, medical service or supplies, including but not limited to chiropractic services, acupuncture, acupressure, reflexology, bonesetting, herbalist treatment, massage or aroma therapy or other alternative treatment.