SOMPO HealthPlus

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

2.    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.

3.    Pre-existing Illnesses
Pre-existing Illnesses shall mean disabilities that existed before the Effective date of Insurancethat the Insured Person has reasonable knowledge of. An Insured Person may be considered tohave reasonable knowledge of a pre-existing condition where the condition is one for which:-
i) the Insured Person had received or is receiving treatment;
ii) medical advice, diagnosis, care or treatment has been recommended;
iii) clear and distinct symptoms are or were evident; or
iv) its existence would have been apparent to a reasonable person in the circumstances.

4.    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:
i) Hypertension, diabetes mellitus and cardiovascular disease.
ii) All tumours, cancer, cysts, nodules, polyps, stones of the urinary system and biliary system.
iii) All ear, nose (including sinuses) and throat condition.
iv) Hernias, haemorrhoids, fistulae, hydrocele, varicocele.
v) Endometriosis including disease of the Reproduction System.
vi) Vertebro-spinal disorders (including disc) and knee conditions.

5.    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.

6.    Mandatory Co-payment
Mandatory Co-Payment shall mean the amount specified in the Schedule of Benefits that the Insured Person must first pay before any incurred eligible expenses are payable under this Policy. The Mandatory Co-Payment shall be deducted per Insured Person per Policy Year.

It shall not apply to the following circumstances.
a.    Emergency treatment, including in Accident cases
b.    Outpatient or follow-up treatments arising from Cancer or Kidney Failure or Critical Illness
c.    Treatment sought at Malaysian Government Hospital

7.    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 pay the difference in Room & Board only.

8.    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.

9.    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:
1.    fees laid down in the Malaysian Medical Association’s Schedule of Fees
2.    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.

10.    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.

11.    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.

12.    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.

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

14.    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.

Note: This list is non-exhaustive. Please refer to the Policy Contract for the full list of terms and conditions under this Policy.
 

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. 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.
6. 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.
7. 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.
8. Any treatment or surgical operation for congenital abnormalities or deformities including
   hereditary conditions.
9. 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.
10. Psychotic, mental or nervous disorders, (including any neuroses and their physiological or
    psychosomatic manifestations).
11. 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.
12. 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.
13. 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.
14. Suicide, attempted suicide or intentionally self-inflicted injury while sane or insane.
15. Private flying other than as a fare-paying passenger in any commercial scheduled airlines
    licensed to carry passengers over established routes.
16. 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.
17. Ionising radiation or contamination by radioactivity from any nuclear fuel or nuclear waste from
    process of nuclear fission or from any nuclear weapons material.
18. 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.
19. Expenses incurred for sex changes
20. Investigation and treatment of sleep and snoring disorders, hormone replacement therapy and
    stem cell treatment.

21. Treatment directed towards development delay / or learning disabilities in children (including
    dyslexia)

    
    Note: This list is non-exhaustive. Please refer to the Policy Contract for the full list of terms
    and conditions under this policy.