SOMPO Health

Please click below to view the following:

• SOMPO Health premium table: Cashless (with medical card facility)
• SOMPO Health premium table: Non-cashless (self-pay & claim)

Malaysians aged 19 to 60 years old and policy is renewable up to 100 years old. Dependent children (unmarried & unemployed) must be 30 days old and under the age of 19 or up to the age of 23 for those registered full time students at a recognised educational institution in Malaysia.

The Policy shall become effective as of the date stated in the Schedule. The Policy Anniversary shall be one year after the effective date and annually thereafter. On each such anniversary, this Policy is renewable at the premium rates in effect at that time as notified by the Company. A notice of 30 days will be given should any premium rate be increased. Renewal will not be invited once you attain the maximum age limit of this product.

This Policy is renewable at the option of the policyholder subject to terms, conditions and termination at each policy anniversary date. The renewal premium payable will increase with age and is not guaranteed. The Company reserves the right to revise the premium rate applicable at the time of renewal. Such changes, if any shall be applicable to all Policyholders irrespective of their claim experiences according to the Company's risk assessment.

Application for change of benefits to a higher plan can only be made on renewal and is subject to acceptance by the Company.

You should provide sufficient and accurate information to us or our intermediary to enable us to advise you on the Hospitalisation and Surgical insurance which suits your needs.

Importance Of Disclosure

Consumer Insurance Contract

Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance wholly for purposes unrelated to your trade, business or profession, you have a duty to take reasonable care not to make a misrepresentation in answering the questions in the Proposal Form and you must answer the questions fully and accurately. Failure to take reasonable care in answering the questions may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. You are also required to disclose any other matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied.

Non-Consumer Insurance Contract

Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for purposes related to your trade, business or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance.

This duty of disclosure for Consumer and Non-Consumer Insurance Contract shall continue until the time the contract is entered into, varied or renewed. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us, any of the information given in the Proposal Form is inaccurate or has changed.

Pre-existing Illnesses 

Pre-existing Illnesses 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:-

• the Insured Person had received or is receiving treatment;
• medical advice, diagnosis, care or treatment has been recommended;
• clear and distinct symptoms are or were evident; or
• its existence would have been apparent to a reasonable person in the circumstances.

Specified Illnesses 

Specified Illnesses shall mean the following disabilities and its related complications, occurring within the first 120 days of Insurance of the Insured Person:

• Hypertension, diabetes mellitus and cardiovascular disease.
• All tumours, cancer, cysts, nodules, polyps, stones of the urinary system and biliary system.
• All ear, nose (including sinuses) and throat condition.
• Hernias, haemorrhoids, fistulae, hydrocele, varicocele.
• Endometriosis including disease of the Reproduction System.
• Vertebro-spinal disorders (including disc) and knee conditions.
   

Waiting Period

Waiting Period shall mean the first 30 days between the beginning of an Insured Person’s disability and the commencement of this Policy date/reinstatement date and is applied only when the person is first covered.
This shall not be applicable after the first year of cover. However, if there is a break in insurance, the Waiting Period will apply again.

Upgraded Room & Board Co-payment

If the Insured Person is hospitalised at a published Room & Board rate which is higher than his/her eligible benefit, the Insured Person shall bear 20% of the other eligible benefits described in the Schedule of Benefits.

Residence Overseas

No benefit whatsoever shall be payable for any medical treatment received by the Insured outside Malaysia, if the Insured resides or travels outside Malaysia for more than ninety (90) consecutive days.

Overseas Treatment

If the Insured Person elects to or is referred to be treated outside Malaysia by the Attending Physician, and subsequently proceeds with such treatment, benefits in respect of the treatment shall be limited to Reasonable and Customary and Medically Necessary Charges for such equivalent local treatment in Malaysia based on the official exchange rate ruling on the last day of the Period of Confinement and shall exclude the cost of transport to the place of treatment provided;
Reasonable and Customary charges which are medically necessary shall be deemed to be:
fees laid down in the Malaysian Medical Association’s Schedule of Fees
average charges of medium-cost hospital treatment shall be the basis of payment for all other related charges applied to similar or equivalent severity of the medical condition being treated.

Reasonable And Customary Charges

Reasonable and Customary Charges shall mean charges for medical care which is medically necessary and it does not exceed the general level of charges being made by others of similar standing in the locality where the charge is incurred, when furnishing like or comparable treatment, services or supplies to individual of the same sex and of comparable age for a similar sickness, disease or injury and in accordance with accepted medical standards and practice could not have been omitted without adversely affecting the Insured Person’s medical condition.

Cooling-off Period

If this Policy shall have been issued and for any reason whatsoever the Insured Person shall decide not to take up the Policy, the Insured Person may return the Policy to the Company for cancellation provided such request for cancellation is delivered by the Insured Person to the Company within fifteen (15) days from the date of issue of the Policy. The Insured Person is entitled to the return of the full premium paid less deduction of medical expenses incurred by the Company.

Unless renewed, the coverage will cease on expiry date and the insurance company shall strictly not be liable for any expenses that take place after the expiry date.

You are advised to keep the receipt as proof of payment of premium.

It may not be advantageous to switch insurance policy / insurer because you may be subjected to new terms and conditions of the new policy or of the new insurer.

This Policy does not cover :-

1. Pre-existing illnesses.
2. Specified Illnesses occurring during the first 120 days of continuous cover.
3. Any medical or physical conditions arising within the first 30 days of the Insured Person's cover or date reinstatement whichever is later except for accidental injuries.
4. Care or treatment for which payment is not required or to the extent which is payable by any other insurance or indemnity covering the Insured and Disabilities arising out of duties of employment or profession that is covered under a Workman's Compensation Insurance Contract.
5. 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.
6. Private nursing, rest cures or sanitaria care, illegal drugs, intoxication, sterilisation, venereal disease and its sequelae, AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS Related Complex) and HIV related diseases, and any communicable diseases required quarantine by law.
7. Any treatment or surgical operation for congenital abnormalities or deformities including hereditary conditions.
8. Pregnancy, child birth (including surgical delivery) and its related complications, 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.
9. Psychotic, mental or nervous disorders, (including any neuroses and their physiological or psychosomatic manifestations).
10. Hospitalisation primarily for investigatory purposes, all diagnostic tests including and not limited to Positron Emission Tomography (PET) Scan, Computed Tomography (CT) Scan, Computed Axial Tomography (CAT) Scan, Magnetic Resonance Imaging (MRI), 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 hyperhidrosis, weight reduction or gain.
11. 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.
12. 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.
13. Suicide, attempted suicide or intentionally self-inflicted injury while sane or insane.
14. Private flying other than as a fare-paying passenger in any commercial scheduled airlines licensed to carry passengers over established routes.
15. War or any 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.
16. Ionising radiation or contamination by radioactivity from any nuclear fuel or nuclear waste from process of nuclear fission or from any nuclear weapons material.
17. 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.
18. Expenses incurred for sex changes
19. Investigation and treatment of sleep and snoring disorders, hormone replacement therapy and stem cell treatment.
20. Treatment directed towards development delay / or learning disabilities in children (including dyslexia)
21. 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 and prescriptions thereof.

1 800 88 9866