个人医疗保险条款（2021 版D款）

Individual Health Insurance Policy

(Version D 2021)

保险人签发的保险合同包含中、英文版本。若两版本有不同解释，以中文版本为准。

The documents issued by the Insurer consist of a Chinese language and an English language version.

In the event of any discrepancy, the Chinese language version shall prevail.

目录 CONTENTS

总则 General Provisions .................................................................................................................. 1

保障地域 Insurance Coverage ......................................................................................................... 2

保险责任 Insurance Benefit ............................................................................................................ 3

责任免除 Exclusions ..................................................................................................................... 10

保险金额、保险费、免赔额和自付比例 Sum Assured, Premium, Deductible and Policy Co-

payment ....................................................................................................................................... 14

保险期间和等待期 Policy Period and Waiting Period .................................................................. 15

医疗服务网络和事先授权 Medical Provider Network and Pre-authorization ............................. 16

保险人义务 The Obligations of the Insurer .................................................................................. 17

投保人、被保险人义务 The Obligations of the Policyholder and the Insured ............................ 18

保险金申请与给付 Insurance Benefits Application and Payment ................................................ 21

年龄的计算及年龄错误的处理 The Calculation and Error Handling of Age .............................. 22

保险合同的变更与解除 Alteration and Cancellation ................................................................... 23

不保证续保 Unguaranteed Renewal ............................................................................................. 24

争议处理与法律适用 Dispute Settlement and Governing Law ................................................... 24

释义 Definitions ............................................................................................................................. 24

中国大地财产保险股份有限公司

个人医疗保险条款（2021 版D款）

Individual Health Insurance Policy

【注册编号Registration Number：C00001032512021072007592】

总则

General Provisions

第一条本保险合同（以下简称“本合同”）由保险条款、投保单或者其他投保文件、保

险单或者其他保险凭证、保险卡、网络医疗机构名册、附贴批单和其他有关约定书构成。凡

涉及本合同的约定，均应当采用书面形式。

Article 1 The Policy Wording, the Policy Rider, the Policyholder application forms, other application

documents, the Insurance Certificate or other certificates, the Insurance Card, Direct Billing Providers List, and any

amendments or endorsements, make up the entire Insurance Policy (hereinafter referred to as the "Policy"). Any

agreement relating to the Policy shall be made in writing.

第二条被保险人本人或者对被保险人具有保险利益的其他自然人和组织，可作为投保

人。

Article 2 The Policyholder can be the Insured person or insurable interest related person or organization.

第三条投保时年龄在十八周岁（含）至九十九周岁（含），经保险人同意，可作为主

被保险人。主被保险人的配偶在投保时年龄不超过九十九周岁，经保险人同意，可作为附

属被保险人。其中，投保时年龄在六十五周岁（含）至九十九周岁（含）的自然人，需要

同时满足以下三个条件，才可作为本保险的主被保险人或附属被保险人：

Article 3 Once accepted by the Insurer, a person aged between eighteen (18) and ninety-nine (99) at the time

of enrollment qualifies as a "Primary Insured". Once accepted by the Insurer, the spouse of the Primary Insured aged

below ninety-nine (99) at the time of enrollment qualifies as an "Insured Dependent". And "Primary Insured" and

"Insured Dependents" aged sixty-five (65) to ninety-nine (99) shall meet the following conditions at the same time.

（一）非首次投保本保险；

Not first time insured under this policy.

（二）投保人在上一个保险期间届满前重新向保险人投保本保险；

The policyholder shall reapply a new Policy prior to the expiration of the previous insurance period.

（三）本合同的保险期间与上一个保险合同的保险期间之间连续不间断。

The period of insurance under this Policy shall be continuous and uninterrupted from the period of insurance

under the previous Policy.

投保时年龄不超过二十一周岁（为全日制在校学生，或者存在身体缺陷或智力障碍的，

年龄不超过二十六周岁），经济上完全依赖主被保险人的主被保险人的未婚子女，经保险人

同意，也可作为附属被保险人。

Once accepted by the Insurer, unmarried children up to the age of twenty-one (21), (full-time students up to the

age of twenty-six (26) who attend school regularly, or children up to the age of twenty-six (26) who are physically

or mentally incapacitated), and depend solely upon the Primary Insured’s support, qualify as "Insured Dependents".

主被保险人和附属被保险人统称为“被保险人”或者“所有被保险人”，单称为“每一

被保险人”“该被保险人”或者“被保险人本人”。

"Primary Insured" and "Insured Dependents" are collectively referred to as "the Insured" and "all the Insured"

and are also referred to as "each Insured Person", "the Insured Person" or "The insured himself/herself".

第四条根据附属被保险人的有无及其与主被保险人的身份关系，本保险中被保险人的

参保方式分设有单人型、夫妇型、亲子型、家庭型，具体由投保人在投保时选择，并载明于

本合同中。

Article 4 The Insurer offers four types of coverage according to the Primary Insured personal relationship status:

Single, Couple, Single Parent Family and Family, which shall be selected by the Policyholder and indicated in this

Policy.

（一）单人型，无附属被保险人；

A. Single: no Insured Dependent;

（二）夫妇型，对应的附属被保险人为主被保险人的配偶；

B. Couple: the Insured Dependent is the spouse of the Primary Insured;

（三）亲子型，对应的附属被保险人为主被保险人的子女；

C. Single Parent Family: the Insured Dependents are the children of the Primary Insured;

（四）家庭型，对应的附属被保险人为主被保险人的配偶和子女。

D. Family: the Insured Dependents are the spouse and children of the Primary Insured;

参保方式为亲子型或者家庭型的，投保人可投保家庭共享保险金额保障方案。投保时及

保险期间内要求被保险人人数不少于三人。

For Single Parent Family or Family coverage, the Policyholder may apply for the Family Shared Limit. The

number of insured shall not be less than 3 people at the time of enrollment and during the Policy Period.

第五条除法律另有规定或者本合同另有约定外，保险金受益人为被保险人本人。

Article 5 Except as otherwise stipulated in the Policy or by the law, the beneficiary of this Policy is the Insured

Person.

第六条保险人将在自本合同生效之日起十日内为每一被保险人发放保险卡，该保险卡

将载明被保险人姓名、保险单号码、保险期间、可选责任、免赔额、自付比例、医疗服务网

络、第三方医疗服务供应商（以下简称“医疗服务供应商”）、理赔申请等有关信息。

Article 6 Once this Policy is underwritten, the insurer shall issue an Insurance Card for every Insured Person,

which outlines the name of the Insured Person, Policy number, Policy period, optional benefits, deductible, Policy

Co-payment，medical provider network, third-party medical service provider (hereinafter referred to as the “Medical

Service Provider”), as well as information for submitting claims.

第七条本保险条款涉及的保险金的上限以人民币表示，经投保人、保险人双方协商确

定，也可为其他等值币别。

Article 7 The currency of this Policy is Renminbi (“RMB”), unless otherwise agreed between the Policyholder

and the Insurer.

保障地域

Insurance Coverage

第八条本保险的保障地域为中国大陆（不含港澳台地区，下同），保险人仅对保险期间

内被保险人在保险人认可的医疗机构发生的保险责任范围内的费用，按照本合同的约定给付

保险金。

Article 8 The Insurer provides coverage for medical treatment in Mainland China (excluding Hong Kong,

Macao and Taiwan). The Policy covers the Insured Persons for Allowable Charges of medical services provided in

the areas of coverage for the plans selected as stated in the Policy.

保险人认可的医疗机构（以下简称“医疗机构”）仅限于中国大陆非合资性质的公立医

院的普通部、特需部、VIP贵宾部和国际诊疗部，以及保险人指定的私立医疗机构。

Medical Provider approved by the Insurer (hereinafter referred to as the “Medical Provider”) is limited to

General department, special need department, VIP department and international medical department of non-joint

venture public hospitals in mainland China, as well as private medical institutions designated by the Insurer.

保险责任

Insurance Benefit

第九条保险责任分设有基本责任（包括：住院医疗保险责任、特殊门诊医疗保险责任、

医疗援助保险责任和住院津贴保险责任）和可选责任（包括：门诊医疗保险责任、健康检查

医疗保险责任和牙科医疗保险责任）。投保人可以单独投保基本责任，也可以在投保基本责

任的同时投保可选责任，但投保人不能单独投保可选责任。本合同项下所有被保险人的保险

责任应当一致。

Article 9 This Policy may include the following benefits: Basic Benefits (Inpatient Benefits, Special Outpatient

Benefits, Medical Aid Benefits, Inpatient allowance Benefits) and Optional Benefits (including Outpatient Benefits,

Wellness Benefits and Dental Benefits). The Policyholder can insure Basic Benefits independently or both Basic

Benefits and Optional Benefits, but Optional Benefits can not be insured independently. The Insurance Benefits of

the Insured People shall be same.

第十条住院医疗保险责任

Article 10 Inpatient Benefits

保险期间内，被保险人因遭受意外伤害或者经过等待期后（免除等待期的不在此限)患

疾病，在医疗机构接受医师推荐的、医学必需的住院治疗，由此发生的、符合通常惯例水平

的医疗费用（以下简称“住院医疗费用”），保险人按照“（住院医疗费用－免赔额）×（1－

自付比例）”计算住院医疗保险金。

During the Policy Period, if the Insured Person suffers from accidental injury or disease after Waiting Period

(except for those exempted from the Waiting Period) and receives Medically Necessary Inpatient treatment

recommended by a Physician within the area of coverage, the Usual and Customary Charges (hereinafter referred to

as the “Inpatient expenses”) resulting from the following expenses are covered in accordance with the Schedule of

Benefits. Inpatient Benefits = (Inpatient expenses - Deductible) * (1 – Co-payment).

上述住院医疗费用包括：

The above Inpatient medical expenses include:

（一）标准单人病房床位费、急诊室费、重症监护病房费、医疗机构提供并出具发票的

膳食和营养配餐费。

A. Room and board: fees for a standard single room, emergency room, Intensive Care Unit, meals and/or special

diets (in accordance with the invoice provided by the hospital);

保险人针对每一被保险人每日的该类费用给付的保险金的上限以本合同载明的为准；投

保家庭共享保险金额保障方案的，保险人针对本合同项下所有被保险人每日的该类费用给付

的保险金的上限以本合同载明的为准。

The maximum of above expenses paid by the Insurer to each Insured Person every day shall be indicated in the

Policy. For the Family Shared Insurance Benefits Security Plan, the maximum of expenses paid by the Insurer to all

Insured People every day shall be indicated in the Policy.

（二）未满十八周岁的附属被保险人住院期间其父亲或者母亲（限一人）陪同住院的加

床费，女性主被保险人或者作为主被保险人配偶的女性附属被保险人住院期间其出生未满十

六周的新生婴儿随同住院的加床费。

B. Companion Bed: a companion bed for a parent accompanying a hospitalized insured child under eighteen

(18) years of age, or for a baby under sixteen (16) weeks accompanying a hospitalized a Female Primary Insured or

the Insured Spouse;

保险人针对每一被保险人每日的加床费给付的保险金的上限为800元；投保家庭共享保

险金额保障方案的，保险人针对本合同项下所有被保险人每日的加床费给付的保险金的上限

为800元。

For each Insured person, the maximum of the benefits for a companion bed within the coverage every day is

RMB 800. For the Family Shared Insurance Benefits Security Plan, the maximum of benefits for companion beds

paid by the Insurer to all Insured People every day is RMB 800.

（三）手术室和恢复室费、手术敷料费。

C. Use of operation room and recovery room, and surgical dressings;

（四）输血、血浆、血浆扩容药物的费用，以及所有相关化验、设备操作、服务的费用。

D. Blood transfusions, blood plasma, blood plasma expanders, and all related testing, equipment and services;

（五）药品费。

E. All medicines;

（六）医师诊疗费。

F. Inpatient Consultation by a Physician or Specialist;

（七）手术医师费和麻醉师费。

G. Surgeon and Anesthesiologist;

（八）护理费。

H. Nursing services;

（九）吸氧费。

I. Oxygen services;

（十）化验费。

J. Laboratory tests;

（十一）检查费。包括但不限于X光检查、超声波检查、超声波心动描记术、计算机断

层扫描、计算机辅助断层血管成像、正电子发射计算机断层扫描、核磁共振检查、磁共振血

管成像、磁共振胰胆管成像、数字减影血管造影、消化道造影、病理穿刺、内窥镜检查的费

用。

K. Diagnostic Tests: including, but not limited to X-rays, ultrasonic examination, echocardiography, computed

tomography (CAT scan), Computed aided tomography angiography, positron emission tomography (PET scan) and

magnetic resonance imaging (MRI), magnetic resonance angiography, magnetic resonance cholangiopan-

creatography, digital subtraction angiography, digestive tract angiography, pathological puncture, endoscopy.

（十二）被保险人作为受体接受器官、骨髓移植的费用。

L. Transplant services: This coverage applies only when the organ or bone marrow transplant recipient is an

Insured Person under this Policy;

（十三）放射治疗、化学治疗、质子重离子治疗、肿瘤靶向疗法、肿瘤免疫疗法、肿瘤

内分泌疗法的费用。

M. Radiation therapy, Chemotherapy，Tumor Therapy with Protons and Heavy Ions, Targeted therapy for tumor,

tumor immunotherapy, Tumor endocrinotherapy;

（十四）由医师实施的呼吸治疗的费用。

N. Respiratory therapy rendered by a Physician;

（十五）由具有相应医疗职业资格的医师实施的物理治疗、职业疗法、语言治疗（包括

为治疗吞咽障碍由语言治疗师实施的电子喉镜检查）的费用。该类治疗应当满足下列全部条

件：

O. Benefits are payable for physical therapy, occupational therapy or speech therapy (including a Video

Laryngoscope for the diagnosis of a swallowing dysfunction performed by a registered speech therapist) provided

by a medically registered physician. This treatment shall meet both of the following conditions

1.为该被保险人医师书面治疗计划（包括短期和长期目标，并提交保险人评估）的一部

分；

Services must be pursuant to a Physician’s written treatment plan, which contains short and long-term treatment

goals and is provided to the Insurer for review.

2.被保险人接受该治疗后，在合理的、可预测的时间内症状会明显好转；

There are significant improvement in the Insured Person’s condition in a reasonable and predictable period of

time after receiving treatment, and

3.疗法复杂或者被保险人病症使得只有具有相应医疗职业资格的医师（包括注册物理治

疗师或者职业医疗师）才能安全、有效实施。

Be of such a level of complexity and sophistication, and/or the condition of the patient must be such that the

required therapy can safely and effectively be performed only by a Physician or a registered physical or

occupational therapist.

（十六）耐用医疗设备购买或者租赁的费用。指医师医嘱要求的、满足基本医疗需要的

康复设备、矫形支具和其他耐用医疗设备购买或者租赁的费用，以及随后修理、更换的费用。

对于患癌症接受属于保险责任范围的乳房切除术的被保险人，其两义乳及可放入义乳的胸衣

费用也属于保险责任范围。

P. Durable Medical Equipment Purchase or Rental fees. The Insurer provides benefits for prosthetic devices

(artificial devices replacing body parts), orthopedic braces and Durable Medical Equipment. The Policy will pay the

purchase or rental charges, and subsequent charges for repairs or replacement, provided it is prescribed by a

Physician and determined by the Insurer to be Medically Necessary and appropriate. If an Insured Person who had

a Mastectomy while covered under this policy, as a result of cancer treatment, the Insurer will allow for two breast

implants or silicone breast forms and the related corset.

康复设备和矫形支具包括但不限于腿、臂、背和颈支具，人造腿、臂、眼。

Prosthetics may include, but are not limited to leg, arm, back, and neck braces; artificial legs, arms and eyes.

第十一条特殊门诊医疗保险责任

Article 11 Special Outpatient Benefits

保险期间内，被保险人因遭受意外伤害或者经过等待期后(免除等待期的不在此限)患疾

病，在医疗机构接受医师推荐的、医学必需的特殊门诊治疗，由此发生的、符合通常惯例水

平的医疗费用（以下简称“特殊门诊医疗费用”），保险人按照“（特殊门诊医疗费用－免赔

额）×（1－自付比例）”计算特殊门诊医疗保险金。

During the Policy Period, if the Insured Person suffers from accidental injury or disease after Waiting Period

(except for those exempted from the Waiting Period) and receives Medically Necessary special outpatient treatment

recommended by a Physician within the area of coverage, the Usual and Customary Charges (hereinafter referred to

as the “special outpatient expenses”) resulting from the following expenses are covered in accordance with the

Schedule of Benefits. Special Outpatient Benefits = (special outpatient expenses - Deductible) * (1 – Co-

payment).

上述特殊门诊医疗费用包括：

The above special Outpatient expenses include:

（一）与门诊手术相关的医师费、检查费、治疗费、手术材料费、药品费、麻醉师和助

理麻醉师费；

A. Medical expenses related to outpatient operation: Physician visit, diagnostic tests, therapy, operation material,

medicine, anesthesiologist and Assistant anesthesiologist.

（二）入院前后三十天（含入院和出院当日）内，被保险人由于该次住院相同原因接受

门诊治疗，由此发生的医生诊疗费、检查费、化验费、药品费；

B. Within thirty (30) days before and after hospitalization (including the day of admission and discharge),

expenses incurred for outpatient treatment due to the same reason for the hospitalization shall include fees of

physician visit or consultation, examination, diagnostic tests and all medicines.

（三）特殊门诊费，包括肾脏透析疗法的费用，恶性肿瘤的电疗、化学治疗、放射治疗、

质子重离子治疗、肿瘤靶向疗法、肿瘤免疫疗法、肿瘤内分泌疗法的费用。

C. Special Outpatient, including renal dialysis therapy, electrotherapy for malignant tumors, Radiation therapy,

Chemotherapy, Tumor Therapy with Protons and Heavy Ions, Targeted therapy for tumor, Tumor immunotherapy,

Tumor endocrinotherapy.

第十二条医疗援助保险责任

Article 12 Medical Aid Benefits:

保险期间内，被保险人发生的下列费用（以下简称“医疗援助费用”），保险人按照“（医

疗援助费用－免赔额）×（1－自付比例）”计算医疗援助保险金。

During the Policy Period, the following expenses are covered in accordance with the Schedule of Benefits.

Medical Aid Benefits = (Medical Aid Expenses - Deductible) * (1 – Policy Co-payment).

（一）紧急医疗运送费

A. Emergency Ground Ambulance Services

指在紧急情况下，出于医学必需以专业救护车将其运送至医疗机构，由此发生的紧急医

疗运送费用。

During the Policy Period, benefits are provided for Medically Necessary emergency ground ambulance

transportation to the medical facilities within the area of coverage and payable in accordance with the Schedule of

Benefits.

（二）异地就医交通费

B. Transportation expenses of off-site medical treatment

指被保险人经过等待期后（免除等待期的不在此限）罹患重大疾病，由于当地医疗条件

限制的原因，经医疗服务供应商授权，被保险人及其一位陪同人员前往中国大陆的其他地区

的医疗机构进行住院治疗，由此产生的公共交通工具费用。

During Policy Period, the Insured Person suffers from Catastrophic Illnesses after Waiting Period (except for

those exempted from the Waiting Period). Because of local medical treatment technology or other reasons, after

contacting the Medical Service Provider in advance for approval, the Insured can be transferred to other medical

provider in Mainland China for inpatient care. In this case, transportation costs hospitalized are provided by the

Insurer.

保险人针对每一被保险人累计给付的异地就医费用保险金的上限为8,000元；投保家庭

共享保险金额保障方案的，保险人针对本合同项下所有被保险人累计给付的异地就医费用保

险金的上限为8,000元。

For each Insured person, the maximum of the benefits for Transportation expenses of off-site medical treatment

within the coverage is RMB 8,000. For the Family Shared Insurance Benefits Security Plan, the maximum of benefits

for Transportation expenses of off-site medical treatment paid by the Insurer to all Insured People is RMB 8,000.

第十三条住院津贴保险责任

Article 13 Inpatient Allowance Benefits

保险期间内，被保险人经过等待期后（免除等待期的不在此限）罹患重大疾病，并因此

在医疗机构接受住院治疗的，对于被保险人每年实际住院日数，保险人按照“（每年实际住

院日数-5）×300”计算住院津贴保险金。保险人针对每一被保险人累计给付住院津贴保险

金的日数以三十日为限。

During Policy Period, the Insured Person suffers from Catastrophic Illnesses after the Waiting Period (except

for those exempted from the Waiting Period) and receive Inpatient treatment in medical provider. Inpatient

Allowance Benefits = (Actual number of hospitalization days per year - 5) * 300. Inpatient Allowance Benefits

are provided by the Insurer to each Insured Person up to thirty (30) days.

投保家庭共享保险金额保障方案，且本合同项下两位以上（含）被保险人在同一日接受

住院治疗的，实际住院日数仅计为一日。保险人针对本合同项下所有被保险人累计给付住院

津贴保险金的日数以三十日为限。

For the Family Shared Limit Plan, if two or more than two Insured People receive Inpatient treatment at the

same day, the number of days in hospital shall be calculated as one day only. Inpatient Allowance Benefits are

provided by the Insurer to all Insured People up to thirty (30) days.

第十四条门诊医疗保险责任

Article 14 Outpatient Benefits

保险期间内，被保险人因遭受意外伤害或者患疾病，在医疗机构接受医师推荐的、医学

必需的门诊治疗（不包括特殊门诊治疗），由此发生的、符合通常惯例水平的医疗费用（以

下简称“门诊医疗费用”），保险人按照“（门诊医疗费用－免赔额）×（1－自付比例）”计

算门诊医疗保险金。

During the Policy Period, if the Insured Person suffers from accidental injury or disease and receives Medically

Necessary Outpatient treatment (excluding Special Outpatient treatment) recommended by a Physician within the

area of coverage, the Usual and Customary Charges (hereinafter referred to as the “Outpatient expenses”) resulting

from the following expenses are covered in accordance with the Schedule of Benefits. Medical Benefits =

(Outpatient expenses - Deductible) * (1 – Co-payment).

上述门诊医疗费用包括：

The above Outpatient Medical expenses include:

（一）医师诊疗费。

A. Outpatient Physician visit, or consultation by a specialist;

（二）检查费。检查费分为大型项目检查费（包括：计算机断层扫描、计算机辅助断层

血管成像、正电子发射计算机断层扫描、核磁共振检查、磁共振血管成像、磁共振胰胆管成

像、数字减影血管造影、消化道造影、病理穿刺、内窥镜检查的费用）和非大型项目检查费

（除上述大型项目检查费外的其他检查项目费，包括但不限于超声波检查、超声波心动描记

术检查的费用）。

B. Diagnostic Tests are divided into large project inspections (including computed tomography (CAT scan),

Computed aided tomography angiography, positron emission tomography (PET scan), magnetic resonance imaging

(MRI), magnetic resonance angiography, magnetic resonance cholangiopancreatography, digital subtraction

angiography, digestive tract angiography, pathological puncture, endoscopy) and non-large project inspections (other

tests except above tests, including but not limited to ultrasonic examination, echocardiography).

（三）急诊室费。

C. Emergency room;

（四）理疗和中医治疗费，包括下列三项类型费用：

D. Therapeutic Services and Traditional Chinese Treatment, including the follow three types of fees:

1.由具有专业理疗资格的医师实施的针灸疗法、顺势疗法的费用。

Acupuncture or Homeopathy treatments, must be rendered by a qualified physician.

2.由具有相应医疗职业资格的医师实施的物理治疗、美式脊椎矫正、职业疗法、语言治

疗（包括为治疗吞咽障碍由语言治疗师实施的电子喉镜检查）的费用。

Benefits are payable for physical therapy, American chiropractic treatment, occupational therapy or speech

therapy (including a Video Laryngoscope for the diagnosis of a swallowing dysfunction performed by a registered

speech therapist) provided by a Physician or a medically registered physician.

这类治疗应当满足下列全部条件：

This therapy shall meet both of the following conditions:

（1）为被保险人医师书面治疗计划（包含短期和长期目标，并提交保险人评估）的一

部分；

Services must be pursuant to a Physician’s written treatment plan, which contains short and long-term treatment

goals and is provided to the Insurer for review.

（2）被保险人接受该治疗后，在合理的、可预测的时间内症状会明显好转；

Produce significant improvement in the Insured Person’s condition in a reasonable and predictable period of

time after treatment, and

（3）疗法复杂或者被保险人病症使得只有具有相应医疗职业资格的医师（包括注册物

理治疗师或者职业医疗师）才能安全、有效实施。

Be of such a level of complexity and sophistication, and/or the condition of the patient must be such that the

required therapy can safely and effectively be performed only by medically registered physician (including registered

physical or occupational therapist).

3.依据注册中医医师的处方开具的中草药费，中医挂号费，诊察费及其他相关费用。

Traditional Chinese Treatment, covers registration fee, diagnostic fee, and traditional Chinese Medicines

prescribed by a registered and qualified traditional Chinese physician.

保险人针对每一被保险人累计给付的理疗和中医治疗费保险金的上限以本合同载明的

为准；投保家庭共享保险金额保障方案的，保险人针对本合同项下所有被保险人累计给付的

理疗和中医治疗费保险金的上限以本合同载明的为准。

For each Insured person, the maximum of the benefits for Therapeutic Services and Traditional Chinese

Treatment within the coverage shall be indicated in the Policy. For the Family Shared Insurance Benefits Security

Plan, the maximum of benefits for Therapeutic Services and Traditional Chinese Treatment paid by the Insurer to all

Insured People shall be indicated in the Policy.

（五）药品费。指依据医师的处方开具的药品的费用。每次门诊开药量以九十日为上限，

每次门诊开药量应当与开药时间间隔相匹配。

E. All medicines. The limitation of dosage prescribed by the physician per visit is 90 days. Dosage prescribed

per visit shall match the time interval described in the prescription.

（六）耐用医疗设备购买或者租赁费。指医师医嘱要求的、满足基本医疗需要的康复设备、

矫形支具和其他耐用医疗设备购买或者租赁费，以及随后修理、更换的费用。对于患癌症接

受属于保险责任范围的乳房切除术的被保险人，其两义乳及可放入义乳的胸衣费用也属于保

险责任范围。

F. Durable Medical Equipment Purchase or Rental fees. The Insurer provides benefits for prosthetic devices

(artificial devices replacing body parts), orthopedic braces and Durable Medical Equipment. The Policy will pay the

purchase or rental charges, and subsequent charges for repairs or replacement, provided it is prescribed by a

Physician and determined by the Insurer to be Medically Necessary and appropriate. If an Insured Person who had

a Mastectomy while covered under this policy, as a result of cancer treatment, the Insurer will allow for two breast

implants or silicone breast forms and the related corset.

康复设备和矫形支具包括但不限于腿、臂、背和颈支具，人造腿、臂、眼。

Prosthetic devices and orthopedic braces may include, but are not limited to leg, arm, back, and neck braces;

artificial legs, arms and eyes.

保险人针对每一被保险人每日的医师诊查费、非大型项目检查费、药品费给付的保险金

的上限以本合同载明的为准。投保家庭共享保险金额保障方案的，保险人针对本合同项下所

有被保险人每日的医师诊查费、非大型项目检查费、药品费给付的保险金的上限以本合同载

明的为准。

For each Insured person, the maximum of the benefits for Outpatient Physician visit, or consultation by a

specialist, non-large project inspections, all medicines every day within the coverage shall be indicated in the Policy.

For the Family Shared Insurance Benefits Security Plan, the maximum of benefits for the above expenses every day

paid by the Insurer to all Insured People shall be indicated in the Policy.

保险期间内，保险人针对每一被保险人累计给付的门诊医疗保险金的上限以本合同载明

的为准，当达到该限额时，该被保险人的门诊医疗保险责任终止；投保家庭共享保险金额保

障方案的，保险人针对本合同项下所有被保险人累计给付的门诊医疗保险金的上限以本合同

载明的为准，当达到该限额时，本合同项下所有被保险人的门诊医疗保险责任终止。

During the Policy Period, the maximum of Outpatient Benefits for each Insured Person shall be indicated by

the Policy. When this limit is reached, outpatient benefits are not payable to the Insured Person. For the Family

Shared Insurance Benefits Security Plan, the maximum of benefits for the above expenses paid by the Insurer to all

Insured People shall be indicated in the Policy. When this limit is reached, outpatient benefits are not payable to all

Insured People.

第十五条健康检查医疗保险责任

Article 15 Wellness Benefits

保险期间内，被保险人在医疗机构发生的下列健康检查医疗费用，保险人按照“健康检

查医疗费用×100%”计算给付健康检查医疗保险金：

During the Policy Period, for the following expenses, the Wellness Benefits under the coverage shall be

calculated as follows: Wellness Benefits = Wellness Medical Expenses * 100%.

（一）全身体检（限一次）费；

Full physical examination (once per Policy Period);

（二）疫苗接种费；

Vaccination;

（三）常规检查化验费。

Routine tests and exams.

保险人针对每一被保险人累计给付的健康检查医疗保险金的上限以本合同载明的为准，

当达到该限额时，该被该保险人的健康检查医疗保险责任终止。

The maximum of Wellness Benefits for each Insured Person shall be indicated by the Policy. When this limit is

reached, Wellness Benefits are not payable to the Insured Person.

第十六条牙科医疗保险责任

Article 16 Dental Benefits

保险期间内，被保险人在医疗机构发生的下列牙科医疗费用，保险人按照“牙科医疗费

用×80%”计算给付牙科医疗保险金：

During the Policy Period, for the following expenses, the Dental Benefits under the coverage shall be calculated

as follows: Dental Benefits = Dental Medical Expenses * 80%.

（一）预防治疗费，包括常规牙科检查、牙齿健康指导、涂氟治疗、洁齿和抛光（预防）、

牙齿清洁检查（限两次）费；

Preventive treatment: Covered Expenses include routine examinations, dental health instruction; fluoride

treatment, scale and polish (prophylaxis); cleaning of teeth up to twice (2) per Policy Period.

（二）基础治疗费，包括汞合金或者复合树脂充填、简单拔牙、牙周刮治、根面平整费，

以及相关口腔X光费。

Basic treatment: Covered Expenses include amalgam or composite fillings, simple extractions, periodontal

scaling, root planning and related pan oral x-rays.

保险人针对每一被保险人累计给付的牙科医疗保险金的上限为2,000元，当达到该限额

时，该被保险人的牙科医疗保险责任终止。

The maximum of Dental Benefits for each Insured Person is RMB 2,000. When this limit is reached, Dental

Benefits are not payable to the Insured Person.

责任免除

Exclusions

第十七条对于被保险人发生的以下费用，保险人不承担给付保险金的责任：

Article 17 Except as otherwise stipulated, the following services, conditions and other items are excluded

from coverage under this Policy:

（一）投保人的故意行为导致的医疗费用；

Medical expenses caused by the intentional act of the Policyholder;

（二）从事违法行为或者故意行为（包括但不限于自残、自杀）引起的或者在这一过程

中发生的伤害、病症治疗及其他相关费用，但被保险人为无民事行为能力的不受此限；

Injuries and/or Illnesses and related expenses resulting or arising from or occurring during the

commission or perpetration of a violation of law, or intentional acts by an Insured Person, including, but not

limited to all self-inflicted Illnesses or Injuries, or suicide. However, the Insured without capacity for civil

conduct is not subject to this limitation;

（三）未经保险人审核通过的既往症的治疗及其他相关费用；

The treatment of Pre-existing Conditions not approved by the Insurer and other related expenses;

（四）在等待期内对约定的相应病症的治疗及其他相关费用；

Services, treatments and related expenses for conditions subject to designated “Waiting Periods” as set

forth in the Policy and on the Schedule of Benefits or Policy Rider;

（五）未取得中国大陆法律法规及中国大陆相关监管机关批准的检查、治疗及相关医疗

服务的所有费用，试验性治疗的所有费用；

Examination, treatment, drugs/medications, and all of related medical service, which are deemed to be

Experimental or Investigational or which is not approved by the laws, regulations or the related National

Regulatory Authorities in Mainland China where the treatment has been received;

（六）根据工伤补偿、职业病或者其他与职业疾病相关的法律法规可从中获得补偿的费

用；

Any services or benefits provided by or available under any Workers’ Compensation law, Occupational

Disease law or similar law concerning job related conditions of any country;

（七）代诊费用，无原始发票的费用，电话咨询费（经由医疗服务供应商指定并授权的

机构除外），没有按时就诊的预约费用，不在执业范围的医疗服务费用，不符合专业认可标

准的医疗费用，非医学必需的费用，超过通常惯例水平的费用；

Reimbursement for photocopies and any other non-medical non-covered expenses. Medical consultations

on behalf of someone else or services that were not provided for the insured persons or that occur when the

insured is not present. Telephonic consultations (institutes authorized and approved by the Medical Service

Provider are excluded) or missed appointments，any services not necessary for medical care, as well as medical

services that do not meet professionally recognized standards. Treatment, services, benefits, supplies, drugs

and/or Emergency Medical Evacuation services that are not Medically Necessary, not recommended or

approved by a doctor or not rendered within the scope of a doctor’s license. Charges in excess of the Usual

and Customary Charges for any covered procedure.

（八）为个人舒适或者方便而产生的费用，包括但不限于电视、套房及其相关设施、雇

佣护工、房屋打扫、访客膳食和住宿、电话、家庭设备、旅行费；

Personal comfort and convenience items, including but not limited to: television, suites, housekeeping

services, house cleaning, guest meals and accommodations, telephone charges, take home supplies, travel

expenses.

（九）保险期间届满后发生的费用，但按疗程将在保险期间届满之日起九十日内服用的

药品费用不受此限；

Claims and costs for medical treatment occurring after the expiration date of the Policy, and any portion

of a covered prescription to be used within 90 days beyond the expiration date are not subject to this limit.

（十）健康检查费、功能医学检查（包括但不限于全套个人化营养评估、抗氧化维生素

分析、氧化压力分析、营养与毒性元素分析、肠道免疫功能分析）费，疫苗接种费，出于行

政或者管理事务目的（包括但不限于与投保保险、招聘、入学或者运动相关的体格检查）发

生的检查费，但健康检查医疗保险责任不在此限；

Health check-ups, functional medical examination (including but not limited to a full set of Personalized

Nutrition Assessment, Antioxidant Vitamin Analysis, Oxidative Stress Analysis, Nutrient & Toxic Element

Analysis, Gut Immunity Analysis), vaccination, and tests expenses necessary for administrative purposes (e.g.

including, but not limited to determining insurability, employment, school or sport-related physical

examinations), except under Wellness Benefits.

（十一）非药品准字号的药品费和非（食）药监械号的设备费，包括但不限于保健品、

膳食补充剂、药妆、戒烟药物、食欲抑制剂、头发再生药物、抗光老化药物、美容用品、大

剂量维生素、维他命、健康滋补类中草药、膏方药费，草药代加工成粉剂、药丸、胶囊、胶

的费用或者其他制剂发生的加工费用；

Drugs or equipment not approved by China Food and Drug Administration (CFDA), including but not

limited to health products, dietary supplements, cosmeceutical, smoking cessation drugs, appetite

suppressants, hair regenerative drugs, anti-photo aging drugs, cosmetic and beauty aids, megavitamins,

vitamins; Traditional Chinese Medicine for general health improvement; Chinese herbal paste, any herb

processing charge related to powder, pill, capsule, paste, mastic and other preparation.

（十二）未经被保险人医师推荐而产生的医疗费用；

Medical expenses incurred without the recommendation of a Physician;

（十三）视觉治疗及其他相关费用，包括但不限于激光角膜切开术，准分子激光原位角

膜磨镶术，老视、屈光不正（近视、远视、散光）校正手术及相关费用；

Services and supplies related to visual therapy, Radial keratotomy procedures, Lasik, or eye surgery to

correct refractive error or deficiencies; Services or treatment for astigmatism, hyperopia, myopia or

presbyopia.

（十四）专业护士家庭护理费，临终关怀费，静养疗法、监护及家居照料费，在护理之

家、养老院发生的护理费，为休息、观察而实施的环境疗法费，在任何长期护理机构、矿泉

疗养地、水疗院门诊、康复机构、疗养院、养老院等非保险人认可的医疗机构接受的服务或

者治疗及其他相关费用，医疗机构已实际成为或者倾向作为被保险人住家或者常住处情形

下发生的费用，完全或者部分因为家庭原因的住院医疗费用；

Home Health Nursing, Hospice Care, Rest cures, Custodial Care or homelike care, Care in a nursing

home or home for the aged; Milieu therapy for rest and/or observation; Services or treatment in any long

term care facility, spa, hydro clinic, Rehabilitation institution, sanatorium or home for the aged that is not a

Hospital as defined in this Policy; Hospital costs if the Hospital effectively becomes, or could be treated as,

being the Insured Person’s home or permanent abode; Hospital costs where Admission to the Hospital is

arranged wholly or partly for domestic reasons.

（十五）选择性手术和治疗及其他相关费用，仅为改善或者提高目前身体状况（包括但

不限于中医调理）而发生的、非医学必需的费用；

Elective surgery and procedures, treatment and/or surgery that is not Medically Necessary, Treatment

that is provided for the sole purpose of improving or enhancing the quality of an existing condition (including,

but not limited to Chinese traditional treatment for general health improvement) and does not meet the

definition of Medically Necessary treatment.

（十六）性别转换症治疗费，性障碍治疗费，以及上述相关并发症治疗及其他相关费用，

任何原因和形式的美容、整容、非医学必需的整形费，包括以美容为目的牙齿处理费，义齿、

高嵌体、种植牙、贴面费用；

Treatment costs for sexual transformation, sexual dysfunctions or inadequacies, the related

complications and other expenses. Any cause or form of services or supplies for aesthetic treatment, cosmetic

surgery and plastic surgery that is not medically necessary, including cosmetic surgery or supplies or

procedures; false teeth; onlays; dental Implants; veneers.

（十七）对未表现出可疑细胞行为（如近期大小、形状、颜色发生改变）的良性皮肤损

害（包括但不限于黄褐斑、皮肤白斑、色素沉着）的治疗、祛除及其他相关费用，蜘蛛脉、

除瘢痕疙瘩型外的其他瘢痕、纹身去除、皮肤变色治疗及其他相关费用，非医学必需的对白

癜风、浅表静脉曲张的治疗及其他相关费用；

Treatment or removal of benign skin lesions (including, but not limited to chloasma, leukoderma,

chromatosis) not demonstrating evidence of suspicious cellular activity such as, but not limited to, recent

changes in size, shape or color; Treatment of, or surgery for, Vitiligo, superficial varicose veins that are not

Medically Necessary, spider veins, non-keloid scars, tattoo removal, or other skin discolorations.

（十八）与脱发相关的治疗及其他相关费用，包括但不限于男性型脱发或者其他种类秃

发的治疗费，以激光、电解、蜡或者其他方法祛除毛发费，发生男性型脱发、女性与年龄相

关脱发、疾病或者意外伤害导致的脱发等情形时的头发移植费；

Treatment of hair loss including, but not limited to: hairplasty for male pattern alopecia or any

alopecia; the temporary or permanent removal of hair by laser, electrolysis, waxing, or any other means;

hair transplants to correct permanent hair loss that is clearly caused by disease or Injury, for male pattern

baldness, or age-related thinning in women.

（十九）戒烟治疗及其他相关费用，减肥和任何为减肥接受的治疗、咨询、饮食费，减

肥代餐费，与单纯性肥胖和病理性肥胖相关治疗（包括但不限于胃旁路术、胃球置放术、胃

分隔术、空肠回肠旁路术）及减肥相应并发症治疗及其他相关费用；

Smoking cessation treatments; Weight reduction and the cost of any and all treatments for weight

reduction or weight reduction programs; Medical fast diets, weight loss programs and educational dietary

counseling related to weight loss efforts; Health care services and associated expenses related to or

associated with treatment of morbid or non-morbid obesity, including, but not limited to: gastric bypass,

gastric balloons, gastric stapling, jejunal ileal bypass, and any other procedures or complications arising

therefrom.

（二十）器官移植供体费用、器官来源费用、低温储藏费用；

All expenses related to the organ transplant donor, organ transplant donor search and transplant tissue

storage fees.

（二十一）基因咨询、筛查、检查和治疗及其他相关费用；

Genetic counseling, screening, testing or treatment.

（二十二）与生育相关的医疗费用，包括但不限于怀孕、分娩、流产、助孕（包括但不

限于受胎药、人工授精、试管授精、配子输卵管内移植、受精卵输卵管植入术、代理怀孕）、

不孕不育、生育控制、孕前准备以及由此导致的并发症治疗及其他相关费用；

Medical expenses related to fertility, including but not limited to pregnancy, delivery, miscarriage,

promoting gestation (fertility/infertility drugs, artificial inseminations, in-vitro fertilization, gamete

intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), surrogate mother), infertility, birth

control，pre-pregnancy examinations, the resulting complications and other related costs. But Maternity and

Newborn Infant Care Benefits are not limited to this limitation.

（二十三）因溶剂滥用、毒品滥用、酒精（酒精过敏、误服酒精除外）、或者任何成瘾

物直接或者间接引起的伤害或者疾病的诊断、检查、治疗及其他相关费用；因使用违反中国

大陆法律的疫苗和药物、非医师医嘱要求药物或者非医师医嘱要求用量直接或者间接引起

的伤害或者疾病的诊断、检查、治疗及其他相关费用；

Diagnosis, examination and treatment of any Illness or Injury arising directly or indirectly from alcohol

consumption (except for alcohol allergy, accidental alcohol ingestion) or drug abuse or addictive conditions of

any kind. Diagnosis, examination and treatment for any Injuries and Illnesses directly or indirectly caused by,

contributed to or resulting from the Insured Person's use of vaccinations prohibited by law in Mainland China,

or any drugs or medicines that are not taken in the dosage or for the purpose prescribed by the Insured

Person's Physician.

（二十四）牙科医疗及其他相关费用，但牙科医疗保险责任不在此限；

Dental treatment and other related expenses, except under the Dental Benefits.

（二十五）耐用医疗设备使用和保养指导费，定制或者改造任何交通工具、洗浴设备或

者住宅设备费，助听器、人工耳蜗、血压计、体温计、听诊器、自动轮椅或者自动床、舒适

设备（如电话托臂和床上多用桌）及其他类似设备费；非手术中必需的假体、矫正器具或者

相似的器具费，但医师认为治疗必不可少的假体或者耐用医疗设备不在此限；

Instructions for the use and care of Durable Medical Equipment, Customizing any vehicle, bathroom

facility or residential facility, Costs of Hearing aids, Artificial cochlea, Sphygmomanometer, thermometer,

stethoscope, Motor driven wheelchairs or bed, Comfort items (such as telephone arms and over bed tables)

and similar items. Prosthesis and corrective devices which are not medically required intra-operatively or

equivalent appliances, except prosthesis or Durable Medical Equipment used as an integral part of treatment

prescribed by a Physician.

（二十六）矫正鞋或者其他脚支撑器材（包括但不限于足弓支撑器、矫正器或者任何其

他预防性的服务或者器材）费，任何用于治疗弱足、矫形足、不稳足、扁平足或者足弓塌陷

的器材费，任何与跗骨、跖骨相关的医疗费，对脚表面损害的（如鸡眼、老茧、角质化）医

疗费，但有关骨外露、肌腱或者韧带的手术不在此限；

Orthopedic shoes or other supportive devices for the feet, such as, but not limited to, arch supports and

orthotic devices or any other preventative services and supplies; any devices resulting from the diagnosis of

weak, strained, unstable or flat feet or fallen arches, or any tarsalgia or metatarsalgia; or specified lesions of

the feet, such as corns, calluses, and hyperkeratosis, except for operations which involve the exposure of bones,

tendons, or ligaments.

（二十七）常规足部医疗及其他相关费用，但因意外伤害或者疾病引起的足部治疗情形

不在此限；

Routine podiatry or other foot treatment not resulting from an Illness or Injury.

（二十八）中国政府为了防止传染病扩散蔓延要求被保险人进行医学隔离观察等强制性

措施期间发生的检查检测费、食宿费、服务费和运送费等与治疗不相关的费用；

Expenses unrelated to treatment, such as the cost of examination, meals and accommodations, service fee

and transportation, incurred during the period when the local government is required to take compulsory

measures such as medical isolation and observation to prevent the spread of infectious diseases.

（二十九）生长激素治疗及其他相关费用，但经医疗服务供应商批准的医学必需情形不

在此限；

Growth hormones and related expenses, unless Medical Necessary and Pre-authorized by the Medical

Service Provider.

（三十）与精神和心理障碍相关的医疗费用，包括但不限于神经性贪食症、神经性厌食

症、悲伤辅导和悲伤治疗、注意力缺陷症、注意缺陷多动障碍，心理缺陷或者心理发育迟缓

评估治疗及其他相关费用;

Mental Health and Psychotherapeutic Treatment Benefits: including but not limited to treatment for

bulimia, anorexia, Bereavement, Attention Deficit Disorder (ADD), and Attention Deficit Hyperactivity

Disorder (ADHD), evaluation and treatment of mental deficiency or retardation, and other related expenses.

（三十一）睡眠检查和治疗费，对疑为发作性睡眠或者阻塞性呼吸暂停症状的检查和治

疗费；

Sleep Tests and treatments for suspected Narcolepsy or Obstructive Sleep Apnea must be Pre-authorized

by the Medical Service Provider.

（三十二）先天性疾病和症状治疗费；

Congenital Conditions and Birth Anomalies.

（三十三）因健康原因被医师建议不宜旅行的被保险人执意旅行引起的伤害或者病症的

治疗及其他相关费用；

Health care services associated with conditions as a result of traveling against medical advice.

（三十四）对由下列任何异常风险引起的伤害的治疗及其他相关费用：参加或者受训职

业体育运动、高风险运动，战争和恐怖活动，放射材料辐射或者核燃料燃烧，主动置身于风

险，但抢救他人性命情形不在此限。

Exceptional Risks:

 Treatment as a consequence of Injury sustained while participating in or training for any

professional sports or High Risk Sports.

 Treatment as a consequence of Injury sustained as a consequence of war and acts of Terrorism.

 Contamination by radioactivity from any nuclear material or from the combustion of nuclear fuel.

 Treatment for any loss or expense of whatsoever nature directly or indirectly arising out of,

contributed to, caused by, resulting from, or in connection with needless self-exposure to peril or

bodily Injury, except in an endeavor to save human life.

保险金额、保险费、免赔额和自付比例

Sum Assured, Premium, Deductible and Policy Co-payment

第十八条每一被保险人的保险金额由投保人在投保时选择，并载明于本合同中。投保

家庭共享保险金额保障方案的，本合同项下所有被保险人共用一个保险金额。

Article 18 The sum assured for the Insured Person shall be selected by the Policyholder and indicated in this

Policy. For the Family Shared Insurance Benefits Security Plan, all Insured People in this Policy shall have a shared

sum assured.

第十九条保险费由保险人在承保时计算确定。

Article 19 The premium of the Insured shall be calculated and determined by the insurer at the time of

underwriting.

第二十条免赔额由投保人投保时选择，并载明于本合同中。住院医疗保险责任、特殊

门诊医疗保险责任、医疗援助保险责任和门诊医疗保险责任共用一个免赔额。投保共享免赔

额保障方案的，本合同项下所有被保险人共用一个免赔额。

Article 20 The Deductible shall be selected by the Policyholder and indicated in this Policy. Inpatient

Benefits, Special Outpatient Benefits, Medical Aid Benefits and Outpatient Benefits have a shared Deductible.

For the Family Shared Insurance Benefits Security Plan, all Insured People in this Policy shall have a shared

sum assured.

以下费用可抵扣免赔额：

The deductibles can be offset in the following cases:

（一）被保险人通过社保个人账户支付或者使用社保挂号后，使用现金（银行卡）支付

的费用，可用作保险索赔或者抵扣本保险的免赔额；

The expenses paid by the insured through personal social insurance account, or paid in cash (bank cards)

after registered with social insurance ID can be used as insurance claim or offset by deductibles of this Policy.

（二）被保险人通过社保统筹支付、社保附加支付和其他支付的费用，可用作抵扣本保

险的免赔额，但不可用作保险索赔；

The expenses paid by the insured through social insurance pooling, social security additional payment

and others can be offset by deductibles of this Policy, but insurance claim is not allowed.

（三）属于本合同保险责任范围，但已由其他商业保险赔付的费用，可用作抵扣本保险

的免赔额，但不可用作保险索赔。

The expenses covered by the insurance liability, but have been compensated by other commercial

insurance, can be offset by deductibles of this Policy, but insurance claim is not allowed.

第二十一条自付比例具体由投保人在投保时选择，并载明于本合同中。

Article 21 The Insurer currently offers Policy Co-payment options which shall be selected by the

Policyholder and indicated in this Policy.

保险期间和等待期

Policy Period and Waiting Period

第二十二条本合同保险期间为一年，具体起讫时间由投保人与保险人协商确定，并载

明于本合同中。

Article 22 Except as otherwise agreed, the Policy Period is defined as one year. The effective date will be the

one approved by the Policyholder and the Insurer, which shall be indicated in this Policy.

第二十三条等待期为三十日。同时满足以下三个条件的，免除等待期：

Article 23 The Waiting Period is 30 days. The Waiting Period shall be excluded if the following three

conditions are met at the same time:

（一）非首次投保本保险；

Not first time insured under this policy;

（二）投保人在上一个保险期间届满前重新向保险人投保本保险；

The policyholder shall reapply a new Policy prior to the expiration of the previous insurance period;

（三）本合同的保险期间与上一个保险合同的保险期间之间连续不间断。

The period of insurance under this Policy shall be continuous and uninterrupted from the period of

insurance under the previous Policy.

医疗服务网络和事先授权

Medical Provider Network and Pre-authorization

第二十四条本合同医疗服务网络如下：

Article 24 The Medical Provider Network under this Policy is as follows:

保险人建立了医疗服务网络，并将定期或者不定期向投保人和被保险人通报，被保险人

也可登陆保险人指定的互联网站或者致电查询相关信息。被保险人在保险人医疗服务网络内

的医疗机构（以下简称“网络医疗机构”）接受治疗并出示保险卡的，对于被保险人发生的

保险责任范围内的、应当由保险人承担的住院费用，保险人将直接与相关医疗机构结算，无

需被保险人先行给付。保险人有权要求被保险人在网络医疗机构内接受住院治疗。

The Insurer maintains a network of medical providers and will inform the Policyholder and the Insured regularly

or irregularly about any change. The relevant information is also available for consultation on the website or

telephone line designated by the Insurer. In case the Insured shall receive medical treatment from a medical provider

within the Insurer’s network (hereinafter referred to as the "Network Provider"), shall enjoy direct billing services

by showing the Insurance Card, without advance payment by the Insured. The Insurer has the right to require the

Insured to receive treatment at a Network Provider.

被保险人在网络医疗机构接受治疗的，对于其发生的不属于保险责任范围、应当由其负

担但医疗机构未向其本人收取的医疗费用，在接到保险人或者其授权的机构通知后，被保险

人应当在三十日内退还相应款项；未在三十日内退还相应款项的，保险人有权向其继续追偿

相应费用。

After the Insured Person receives treatment from a Network Provider, if such expense is not covered by

the insurance benefits, the cost shall be borne by the Insured himself. If such expense is not charged by the

medical provider to the Insured Person directly, the Insurer or its authorized agencies will notify the Insured

who will have to refund such expense within thirty (30) days of this notification. Failure to refund this amount

will result in the continuing to claim compensation.

第二十五条有关事先授权事项如下：

Article 25 Pre-authorization Requirements are as follows:

（一）事先授权

A. Pre-authorization

被保险人发生下列事项前，应当在预定开始治疗日期前至少五个工作日向医疗服务供应

商提交事先授权申请表：

For the following services, the Insured Person shall submit the pre-authorization application form to the Medical

Service Providers of the Insurer, at least 5 working days prior to the performance of those services:

1.住院治疗；

Hospitalization;

2.化学治疗、放射治疗、肿瘤靶向疗法、肿瘤内分泌疗法、肿瘤免疫疗法、质子重离子

治疗、血液或者腹膜透析，以及需全身麻醉的门诊手术；

Chemotherapy, Radiation therapy, Targeted therapy for tumor, Tumor endocrinotherapy, Tumor immunotherapy,

Tumor Therapy with Protons and Heavy Ions, Hemodialysis & Peritoneal dialysis treatment, Outpatient surgery

requiring general anesthesia;

3.购买或者租用非一次性耐用医疗设备，包括但不限于胰岛素泵及其配套器械；

Purchase or rental of Durable Medical Equipment (DME), including but not limited to insulin pumps and

supplies;

4.购买或者接种每剂超过8,000元的药剂或者疫苗。

Medications or immunizations in excess of RMB 8,000 per refill.

对于被保险人事先授权的申请，医疗服务供应商将予以书面回复并有权要求被保险人

在网络医疗机构内接受治疗。被保险人应当在收到书面许可回复后开始接受治疗，保险人要

求被保险人在医疗服务网络接受治疗的，被保险人应当予以配合。未获得医疗服务供应商书

面许可回复擅自接受治疗的，保险人保留不承担相关保险责任的权利。

Once the Insured has submitted the application for pre-authorization, the Medical Service Provider will reply

in writing and reserves the right to request the use of a Network Provider. The Insured shall start treatment after

receiving the written reply. The Insured Person shall cooperate with the Insurer’s requirement on the use of a Network

Provider. The Insurer reserves the right to deny claims arose from services mentioned above without obtaining

pre-authorization prior to the performance of those services.

发生紧急情况的，被保险人可在就近网络或者非网络医疗机构接受治疗,但应当在开始

接受治疗后四十八小时内通知医疗服务供应商。保险人将对该次治疗是否属紧急情况予以审

核。

In instance of an emergency, the Insured Person should receive treatment at the nearest Hospital or Provider,

even if it is not part of the Network Providers. The Medical Service Provider shall be notified within 48 hours of the

service, and reserves the right to verify whether the treatment received is for an emergency.

（二）其他

B. Others

1.被保险人、相关人员或者医疗机构可致电医疗服务供应商，了解事先授权、网络医疗

机构相关情况；

The Insured, authorized personnel or the medical institution can inquire Medical Service Provider about

relevant information for the pre-authorization or Network Providers.

2.被保险人获得医疗服务供应商许可回复，不意味着其发生的全部或者部分医疗费用均

属于保险责任范围，保险人按照本合同约定承担保险责任。

The attainment of the pre-authorization letter from the Medical Service Provider doesn't guarantee the

coverage of all medical expenses incurred. These expenses shall be covered in accordance with the Schedule

of Benefits.

保险人义务

The Obligations of the Insurer

第二十六条保险人同意承保的，应当及时向投保人签发保险单或者其他保险凭证。

Article 26 Once this Policy is underwritten, the Insurer shall timely issue the Insurance Policy or other insurance

certificate to the Policyholder.

第二十七条保险人认为保险金申请人提供的有关索赔的证明和资料不完整的，应当及

时一次性通知保险金申请人补充提供。

Article 27 If the Insurer considers the claim evidence and documents provided by claimant as incomplete, it

shall promptly notify the claimant to provide the complementary evidence or documents.

第二十八条保险人收到保险金申请人提供的本保险条款“保险金申请与给付”部分约

定的保险金申请证明和资料后，应当及时作出是否属于保险责任的核定；情形复杂的，应当

在三十日内作出核定。

Article 28 The Insurer shall, after the receipt of claim evidence and documents as required by the “Insurance

Benefits Application and Payment” provision in this Policy, ascertain and determine in a timely manner whether the

claim is within the liability of the Insurer. In case of complicated situation, the Insurer shall ascertain and determine

within thirty (30) days.

保险人应当将核定结果通知保险金申请人。对属于保险责任的，在与保险金申请人达成

给付保险金的协议后十日内，履行给付保险金的义务；对不属于保险责任的，应当自作出核

定之日起三日内向保险金申请人发出拒绝给付保险金通知书，并说明理由。

The Insurer shall notify the result to the claimant, and shall fulfill its obligations for such payment within ten

(10) days after an agreement is reached with the insurance benefit applicant on the amount of payment. Within three

(3) days after the Insurer has ascertained the claim according to the above provision, the Insurer shall issue to the

claimant a notice which states the reasons declining payment of the insurance benefits for any events not falling

within the scope of coverage.

第二十九条保险人自收到保险金申请人提供的本保险条款“保险金申请与给付”部分

约定的保险金申请证明和资料之日起六十日内，对其给付保险金的数额不能确定的，应当根

据已有证明和资料可以确定的数额先予给付；保险人最终确定给付保险金的数额后，给付相

应的差额。

Article 29 Should the amount of the insurance benefits cannot be determined within sixty (60) days of receipt

of the claim and relevant evidence and documents as required by “Insurance Benefits Application and Payment” in

this Policy, the Insurer shall deliver payment of the amount which can be determined by the evidence and documents

obtained. The Insurer shall pay the balance after the final amount of the insurance benefits is determined.

第三十条保险期间内保险人将定期或者不定期向投保人或者被保险人通报不符合通常

惯例水平的医疗机构，供被保险人就诊参考。

Article 30 The Insurer shall, during the Policy Period, inform the Policyholder and the Insured Persons of

medical providers in excess of the Usual and Customary Charge regularly or irregularly for reference.

投保人、被保险人义务

The Obligations of the Policyholder and the Insured

第三十一条投保人应当在订立本合同时一次交清保险费。投保人未按照本合同的约定

交清保险费的，本合同不生效。

Article 31 Except as otherwise agreed, the Policyholder shall pay the Premium in lump sum as agreed in this

Policy. If the Policyholder fails to make the timely payment of Premium, this Policy will not take effect.

第三十二条订立本合同时，保险人就被保险人的有关情况提出询问的，投保人、被保险

人应当如实告知。

Article 32 If the Insurer, prior to the underwriting of this Policy, requires information about the Insured Person,

the Policyholder and the Insured Person shall make a full and accurate disclosure.

投保人、被保险人故意或者因重大过失未履行前款规定的义务，足以影响保险人决定是

否同意承保或者提高保险费率的，保险人有权解除本合同。

The Insurer shall have the right to cancel this Policy, in the case that the Policyholder intentionally or by gross

negligence fails to perform such obligation of making a full and accurate disclosure specified in the preceding

paragraph to the extent that it would materially affect the Insurer's decision whether or not to underwrite this Policy

or increase the premium rate.

前款规定的合同解除权，自保险人知道有解除事由之日起，超过三十日不行使而消灭。

The cancellation right under the preceding paragraph shall be extinct if not exercised beyond thirty (30) days,

commencing on date when the Insurer knows the grounds of cancellation.

投保人、被保险人故意不履行如实告知义务的，保险人对于本合同解除前发生的保险事

故，不承担给付保险金的责任，并不退还保险费。

If the Policyholder and the Insured Person intentionally fail to perform its obligation of making a full

and accurate disclosure, the Insurer shall bear no obligation for making any payment of the insurance benefits

for the occurrence of any insured event that occurred prior to the cancellation of the contract, and for

refunding the premiums paid.

投保人、被保险人因重大过失未履行如实告知义务，对保险事故的发生有严重影响的，

保险人对于本合同解除前发生的保险事故，不承担给付保险金的责任，但退还保险费。

If the Policyholder and the Insured Person by gross negligence fail to perform the obligation of making

a full and accurate disclosure and materially affects the occurrence of an insured event, the Insurer shall bear

no obligation for making any payment of the insurance benefits for any insured event occurring before the

cancellation of the contract, but the premiums paid shall be refunded.

保险人在本合同订立时已经知道投保人、被保险人未如实告知的情况的，保险人不得解

除本合同；发生保险事故的，保险人承担给付保险金的责任。

If the Insurer is aware that the Insured Person failed to make a full and accurate disclosure, the Insurer has no

rights to cancel the Policy; in the case of an insured event, the Insurer shall bear the obligation of benefits payment.

第三十三条成为本合同的主被保险人，即意味着主被保险人及其代表的附属被保险人

同意任何医疗机构、医师、药剂师等向保险人提供保险人认为处理本合同相关事宜所必要的

医疗信息（包括完整医疗病历和诊断）。保险人将对这些信息保密。

Article 33 The Primary Insured and the Insured Dependents, when applying for enrollment, consent to any

medical institution, physician, pharmacist to render all information determined by the Insurer to be necessary,

inclusive of medical history and diagnosis. The Insurer shall maintain information confidential.

成为本合同的主被保险人，也意味着主被保险人及其代表的附属被保险人同意保险人将

所有医疗信息提供给相关机构以处理本合同相关事宜。

The Primary Insured and the Insured Dependents, when applying for enrollment, authorize the Insurer to

provide records, concerning such Insured Person, including diagnosis and medical history to the relevant authorities

for purposes of administration of this Policy.

第三十四条投保时，被要求填写健康问卷调查表的投保人或者被保险人应当如实告知

被保险人的既往症及保险人要求的其他医疗、症状等信息，保险人将进行医疗核保。保险人

根据被保险人既往症的具体情况，对该既往症承担一定保险责任或者不承担保险责任，并具

体载明于本合同。

Article 34 At the time of enrollment, each Policyholder or Insured Person required by the Insurer to fill out a

medical questionnaire shall do so in full and accurately. The Insured shall disclose pre-existing conditions, medical

treatments, symptoms and other related information for the medical underwriting process required by the Insurer.

According to the specific circumstances of the Insured Person, the insurance benefits for the pre-existing conditions

stipulated in this Policy shall be partly covered or not covered by the Insurer, which shall be indicated in this Policy.

第三十五条在保险期间内，发生下列三种情形的，投保人可申请变更被保险人，保险人

按照下列约定予以受理：

Article 35 During the Policy Period, for the following cases, the Policyholder has the right to apply for changes

of the Insured, and the Insurer shall accept as stipulated below:

（一）因主被保险人婚姻状态发生变化需要增加附属被保险人的，投保人应当在其婚姻

状态发生改变之日起三十日内书面通知保险人，经保险人同意，保险人自通知书载明的起始

时间开始对其承担保险责任，并根据“（加人后的参保方式对应的保险费-加人前的参保方式

对应的保险费）×未满期天数”计算收取相应保险费。投保人未在上述约定的时间内通知保

险人的，本合同在本保险期间内无法加保附属被保险人。

A. Should the marital status of an Insured Person change, written notification must be sent to the Insurer within

thirty (30) days. If accepted by the Insurer, the Insurer shall be responsible for benefits from the starting date stated

in the written notification, and corresponding Premium shall be charged on a daily basis. If the Policyholder fails

to inform the Insurer timely, the Insured Dependents shall not be added during the Policy Period.

（二）因主被保险人婚姻状态发生变化或者其他原因需要减少附属被保险人的，投保人

应当在十日内书面通知保险人，并向保险人退还保险卡。保险人自收到通知书之日的次日零

时或者通知书载明的终止时间（以较晚者为准）起终止对相应附属被保险人的保险责任，并

根据“（减人前的参保方式对应的保险费-减人后的参保方式对应的保险费）×未满期天数”

计算收取相应保险费。

B. Should an Insured Dependent need to leave the group due to a marital status change of the Insured Person,

written notification must be sent to the Insurer by the Policyholder within ten (10) days and the Insurance Card is

required to be returned. The Insurer will terminate the coverage for the corresponding Insured Dependent from 0:00

of the next day after notification is received, or the termination date as specified in the notification, whichever is

later. The Premium shall be refunded as per the different premium rates of coverage types and shall be calculated on

a daily basis.

（三）因被保险人（子女除外）在保险期间内生育婴儿需要增加附属被保险人，且投保

人在该婴儿出生后三十日内通知保险人的，保险人自该婴儿出生后第三十一日零时起对其承

担保险责任；投保人在该婴儿出生三十日后通知保险人的，经保险人同意，保险人自接到通

知书之日的次日零时或者通知书载明的起始时间（以较晚者为准）起对该婴儿承担保险责任。

同时，保险人根据“（加保婴儿后的参保方式对应的保险费-加保婴儿前的参保方式对应的保

险费）×未满期天数”计算收取相应保险费。

C. Should the Insured (excluding the dependent children) deliver a newborn child during the Policy Period,

written notification must be sent to the Insurer within thirty (30) days, the child will be covered from 0:00 of the 31st

day after birth. Any request received beyond the thirty (30) day notification period shall result in coverage being

effective from 0:00 of the next day after notification is received or the starting time as specified in the notification

(whichever is later). The Premium shall be charged as per the difference in premium rates between the Single or

Couple coverage and Single Parent Family or Family coverage and calculated on a daily basis.

第三十六条如果被保险人住址、婚姻状态，以及投保本保险时提供的其他信息等发生

重大变化，或者身故，投保人或者被保险人应当及时通知保险人。保险人有权调整承保条件

或者解除本合同。

Article 36 The Policyholder or the Insured must inform the Insurer as soon as reasonably possible, of any

changes related to Insured Persons (such as change of address or marital status) or of any other material changes or

of death that affect information given in connection with the application for coverage under this Policy. The Insurer

reserves the right to alter the Policy terms or terminate the benefits for Insured Persons under this Policy.

第三十七条投保人、被保险人或者保险金申请人知道保险事故发生后，应当及时通知

保险人。故意或者因重大过失未及时通知，致使保险事故的性质、原因、损失程度等难以确

定的，保险人对无法确定的部分，不承担给付保险金的责任，但保险人通过其他途径已经及

时知道或者应当及时知道保险事故发生的不在此限。

Article 37 The Policyholder, the Insured Person or the claimant, in the event of an insured event, shall notify

the Insurer at once after being aware of the accident. In the occurrence the Policyholder, the Insured Person or

the claimant intentionally or by gross negligence fail to perform such obligation and this leads to a difficult

determination of the nature, cause of the accident, or extent of the damage, the Insurer shall not be responsible

for benefits payment on the part that cannot be determined. If the Insurer was notified timely or was informed

through other means about the accident, the Insurer shall bear the cost of the insurance benefits.

前款约定的未及时通知，不包括因不可抗力而导致的通知迟延。

The failure to give timely notice as prescribed in the preceding clause does not include the delay in giving notice

caused by force majeure.

第三十八条投保人住所或者通讯地址变更时，应当及时以书面形式通知保险人。投保

人未及时通知的，保险人按照本合同所载的最后住所或者通讯地址发送的有关通知，均视为

已发送给投保人。

Article 38 The Policyholder must inform the Insurer of any changes of residence or mailing address in writing.

If the Policyholder fails to notify this changes at once, the relevant notice sent by the Insurer according to the last

residence or mailing address recorded in this Policy shall be deemed to have been sent to the Policyholder.

保险金申请与给付

Insurance Benefits Application and Payment

第三十九条被保险人在网络医疗机构接受治疗，该医疗机构受保险人委托免向被保险

人收取与保险人根据本合同本应向保险金申请人给付的保险金数额对应的医疗费用的，或

者保险人已承担相应费用的，保险金申请人不得就此向保险人申请保险金。其他情形，保险

金申请人可根据本合同向保险人申请保险金。

Article 39 The Network Provider has entered into an agreement with the Insurer to arrange direct billing

for the Insured Person. After treatment in the Network Provider, the Insured shall be exempted from the

payment for medical expenses. In the instance the Insurer has made the payment of such covered medical cost,

the Claimant shall have no right to claim for reimbursement of the same. In other circumstances, the claimant

may apply for insurance benefits reimbursement to the Insurer in accordance with this Policy.

向保险人申请保险金时，保险金申请人可从保险人指定网站下载保险金申请表；经保险

金申请人要求，保险人也可通过传真或者电子邮件向其发送申请表。保险金申请人应当完整

地填写申请表的第一部分，并请被保险人主治医师完整填写申请表的第二部分，且在当次治

疗完成后一百八十日内与医疗费用原始收据一并寄至本合同指定地址。被保险人提供的所有

保险金申请资料归保险人所有。

Should an Insured Person apply for reimbursement, the claimant may download the Claim Forms from the

designated website, or upon request the Insurer can also send Claim Forms by fax or e-mail. The Claimant shall

complete the part A of the Claim Form, and Part B shall be completed by the Physician of the Insured. The completed

forms together with the original medical expense receipts shall be submitted to the Insurer within 180 days of

treatment for reimbursement of Covered Expenses. All the Claim documents belong to the Insurer.

第四十条保险人有权对被保险人进行身体检查或者理赔问卷调查。被保险人有义务向

保险人提供保险人要求的所有医疗报告、记录及相关资料，若为处理本合同相关事宜，经保

险人要求，被保险人应当授权许可保险人取得其完整全面的医疗病历。被保险人身故的，保

险人有权要求对该被保险人进行尸检，法律和宗教禁止情形不在此限。

Article 40 The Insurer and the Claims Administrator reserve the right to investigate medical reports and claim

questionnaire of the Insured. The Insured Person shall have the obligation to make available all medical reports,

records, and related documents required by the Insurer. If the Insurer shall request access to the full medical history

for investigation, the Insured shall grant such authorization. In the instance of death, the Insurer and the Claims

Administrator reserve the right to require an autopsy, unless forbidden by law or religious beliefs.

第四十一条本保险属于费用补偿型医疗保险。保险人给付的各项费用保险金，以其发

生的保险责任范围内的费用扣除其已从社会基本医疗保险、公费医疗、大病保险、互助保险、

除本保险外的其他商业保险、其所在的工作单位、公益慈善机构等途径获得的补偿金额后的

余额为上限，但住院津贴保险金不受此限。

Article 41 This Policy is expense reimbursement medical insurance product. Medical expenses within the

scope of coverage of this insurance shall deduct any amounts already covered by social insurance, state-funded

medical system, critical illness insurance, mutual insurance, other insurance plans, work unit, charities. The

remaining balance is the maximum of insurance benefits of each expense paid by the Insurer. But Inpatient

allowance benefits are not subject to this limit.

第四十二条收到保险金后六十个工作日内，如果保险金申请人对理赔结果有争议，可

通过邮寄或者发送电子邮件方式向保险人提交书面申诉书及相关资料，并自行承担获取资料

有关费用，保险人将及时予以处理。

Article 42 Should at any time the Insured Person object with the outcome of a processed claim, he/she may

submit a written appeal by post or e-mail with supporting documents. Appeals should be submitted within sixty (60)

working days after receiving the outcome of a processed claim. Upon appeal, the Insured Person shall bear the cost

of any fees associated with the request for medical records. The Insurer shall review the new information and provide

a response promptly.

第四十三条保险金申请人向保险人请求给付保险金的诉讼时效期间为二年，自其知道

或者应当知道保险事故发生之日起计算。

Article 43 The period of limitation for the claimant to submit a reimbursement request to the Insurer is two (2)

years, calculated from the date when the claimant knows or should have known about the insured event.

年龄的计算及年龄错误的处理

The Calculation and Error Handling of Age

第四十四条被保险人的投保年龄以周岁计算。

Article 44 At the time of enrollment, age of the Insured Person depends on actual age calculated based on the

birth date recorded on the legal identity document.

第四十五条投保人在投保时，应当如实告知被保险人的年龄。若被保险人年龄发生错

误，按照下列约定办理：

Article 45 At the time of enrollment, Policyholder shall make a full and accurate disclosure of the age of the

Insured. If the age of the Insured is wrong, the following agreements can be applied.

（一）投保人申报的被保险人年龄不真实，并且其真实年龄不符合本保险条款第三条所

约定条件的，保险人有权解除本合同，并向投保人退还相应的现金价值；

When Policyholder applies a Policy, if the age of the Insured is wrong and not in conformity with the conditions

stipulated in Article 3 of this insurance clause, the Insurer reserves the right to cancel this Policy and refund the

corresponding Cash Value to Policyholder.

（二）投保人申报的被保险人年龄不真实，致使投保人实交保险费少于应交保险费的，

保险人有权更正并要求投保人补交保险费，或者在给付保险金时按实付保险费和应付保险

费的比例给付；

When Policyholder applies a Policy, if the age of the Insured is wrong which causes that the insurance paid by

the Policyholder is less than the amount payable, the insurer shall have the right to make corrections and require the

Policyholder to make up the payment, or pay the insurance benefits in proportion to the amount actually paid

and the amount payable;

（三）投保人申报的被保险人年龄不真实，致使投保人实交保险费多于应交保险费的，

保险人应当退还多收的保险费。

When Policyholder applies a Policy, if the age of the Insured is wrong which causes that the insurance paid by

the Policyholder is more than the amount payable, the Insurer shall refund the overcharged premium.

保险合同的变更与解除

Alteration and Cancellation

第四十六条除本合同另有约定外，经投保人、保险人双方协商同意后，可变更本合同的

有关内容，在保险单或者其他保险凭证上加以批注或者附贴批单后生效，或者由投保人和保

险人订立合同变更书面协议后生效。

Article 46 Except as otherwise agreed in this Policy, the relevant provisions can be modified after its initiation,

upon mutual agreement between the Policyholder and the Insurer. The changes shall come into effect after being

included in writing in this Policy, others insurance certificate or with an endorsement, or after a written agreement

amendment has been signed between the Policyholder and the Insurer.

第四十七条未发生保险事故，被保险人或者受益人谎称发生了保险事故，向保险人提

出赔偿或者给付保险金请求的，保险人有权解除本合同，并不退还保险费。

Article 47 Should an Insured lie about the insurance event, and applies for insurance benefits, the Insurer

reserve the right to terminate the insurance Policy for the corresponding Insured Person, without refunding the

Premium.

投保人、被保险人故意制造保险事故的，保险人有权解除本合同，不承担赔偿或者给付

保险金的责任，并不退还保险费。

Should the Policyholder or the Insured create an insurance event on purpose, the Insurer reserves the right to

terminate the insurance liability for the corresponding Insured Person, without refunding the Premium.

保险事故发生后，投保人、被保险人或者受益人以伪造、变造的有关证明、资料或者其

他证据，编造虚假的事故原因或者夸大损失程度的，保险人对其虚报的部分不承担赔偿或者

给付保险金的责任。

Should the Policyholder, the Insured or Beneficiary counterfeit the certificate, document and/or other relevant

evidence, fake insurance event or exaggerate the influence of insurance event, the Insurer shall not be responsible

for the fake part.

发生前三款约定的任何情形致使保险人给付保险金或者支出费用的，投保人、被保险人

或者保险金申请人应当退回或者赔偿。

Should any of the three (3) circumstances stated in the above paragraphs cause the Insurer to pay for benefits

or expenses, the Policyholder, the Insured, or the claimant shall return such expenditure or provide compensation to

the Insurer.

第四十八条除法律另有规定或者本合同另有约定外，投保人可以书面形式通知保险人

解除本合同。保险人根据本合同的约定已给付保险金，或者已发生本合同约定的保险事故但

是尚未给付保险金的，投保人不得解除本合同，但是受益人放弃保险金请求权的不在此限。

Article 48 Except as otherwise stipulated in the Policy or by the law, the Policyholder reserves the right to

notify in writing to the Insurer to cancel this Policy. If the Insurer already pay the insurance benefits as stipulated

in the Policy or Insured event happens prior to paying the insurance benefits, the policyholder has no rights

to cancel the Policy, unless the beneficiary abandon the right of Insurance Benefits Application.

投保人解除本合同时，应当提供下列证明和资料：

The Policyholder is requested to provide the following evidence and documents to cancel this Policy:

（一）解除合同通知书；

Notice of cancellation;

（二）保险单或者其他保险凭证、批单；

Insurance policy, other insurance certificates or endorsements;

（三）投保人身份证明；

Identity certificate of the Policyholder;

（四）保险费发票或者收据；

Invoice or receipt of the Insured Premium;

（五）保险人合理要求的其他有关证明和资料。

Other relevant certificates and documents reasonably required by the Insurer.

本合同的效力至保险人接到解除合同通知书之日二十四时或者通知书上载明的合同终

止时间（以较晚者为准）终止。自收到前款约定的证明和资料之日起三十日内，保险人退还

相应的现金价值。

The validity of this Policy shall be terminated at 24:00 of the day when the Insurer receives the notice of

cancellation, or at the termination time specified in the notice (whichever is later). Within thirty (30) days of receipt

of the evidence and documents stipulated in the preceding paragraph, the Insurer shall refund the corresponding Cash

Value.

不保证续保

Unguaranteed Renewal

第四十九条本合同保险期间届满前，投保人可重新向保险人投保本保险，经保险人同

意，交纳保险费，获得新的保险合同。但本保险不保证续保。

Article 49 This Policy does not guarantee the renewal. The Policyholder shall reapply a new Policy which

is approved by the Insurer and pay the Premium after expiration.

争议处理与法律适用

Dispute Settlement and Governing Law

第五十条因履行本合同发生的争议，由当事人协商解决。协商不成的，提交本合同载明

的仲裁机构仲裁；本合同未载明仲裁机构或者争议发生后未达成仲裁协议的，依法向中华人

民共和国人民法院起诉。

Article 50 Disputes arising from the execution and performance of this Policy shall be settled through

negotiation between the parties hereto. Should no settlement be reached, the case in dispute shall be submitted to the

arbitration institution specified in this Policy. Where no arbitration institution is specified in this Policy or no

arbitration agreement is reached after disputes, either party hereinto may bring litigation to the People’s Court of the

People’s Republic of China.

第五十一条与本合同有关的以及履行本合同产生的一切争议处理适用中华人民共和国

（不包括港澳台地区）法律。

Article 51 This Policy is governed by and shall be construed in accordance with the laws of the People’s

Republic of China (not including Hong Kong, Taiwan and Macau).

释义

Definitions

医疗机构：指中国大陆法律或者政府认可的、有常驻执业医师、执业护士，提供住院、

门诊、急诊医疗服务的机构。不包括护理机构、疗养机构、康复机构、养老院、家居服务机

构、酒精或者药物滥用看护机构，以及其他类似目的的机构。

Medical Provider - Means institutions licensed or approved by the law and government in Mainland China,

and inpatient, outpatient and emergency services are rendered by a staff of Physicians who are duly licensed to

Resident medical practitioner and registered professional Nurses. The term Medical Providers do not include

nursing homes, rest home, health resorts, and homes for the aged, establishments for domiciliary care, care

facilities for drug addicts or alcoholics, or similar institutions.

周岁：指以法定身份证明文件中记载的出生日期为基础计算的实足年龄。

Age - Actual age calculated based on the birth date recorded on the legal identity document.

子女：指与主被保险人存在父母－子女关系的婚生或者非婚生子女、养子女和扶养关系

的继子女。

Dependent Children - Include the Primary Insured’s natural children, legally adopted children, and/or step

children who live with the primary Insured in a customary parent-child relationship.

免赔额：指保险期间内被保险人发生的保险责任范围内的费用中由被保险人自行负担

的金额，保险人对此不负责给付保险金。

Deductible - The amount of covered Allowable Charges payable by the Insured Person during the Policy

Period before the Policy benefits are applied. Such amount will not be reimbursed under the Policy.

自付比例：指被保险人发生的保险责任范围内的费用扣除免赔额后剩余部分中须由被

保险人自行负担的比例。

Policy Co-payment - The percentage that the Insured Person will pay of Covered Expenses after the

Deductible is met.

住院：指被保险人确因临床需要，正式办理入院及出院手续，并确实入住医疗机构的正

式病房接受治疗的行为过程。不包括门（急）诊观察室诊疗、家庭病床、挂床住院、其他非

正式的病床住院及不合理住院。被保险人因非医疗目的自行离开病房十二小时以上（含）的，

视为自动出院。被保险人接受日间住院治疗视同住院。

Inpatient - It refers to the process in which the insured Person officially goes through the admission and

discharge formalities and is admitted to the formal ward of the medical institution for treatment due to clinical needs,

excluding diagnosis and treatment in outpatient (emergency) observation room, family sickbed, false

hospitalization, other informal hospitalization and unreasonable hospitalization. The Insured Person shall be

deemed to have been discharged automatically if he/she leaves the ward for at least 12 hours for non-medical

purposes. Day-care Treatment is considered as Inpatient Treatment.

挂床：指住院过程中一日内未接受与入院诊断相关的检查和治疗或者一日内住院不满二

十四小时，遵医嘱到外院接受临时诊疗的不在此限。

False Hospitalization - Refers to during the hospitalization no examination and treatment related to admission

diagnosis in one day is performed or hospitalization time in one day is less than 24 hours, unless required by a

physician to receive temporary treatment in another hospital.

日间住院治疗：指完全出于接受医学必需的治疗目的被保险人以占用医疗机构病床但不

过夜的方式接受的医疗。

Day-care Treatment - Treatment received while an Insured Person occupies a Hospital bed or is charged for

Hospital accommodations for a Medically Necessary stay but does not remain overnight.

门诊：指以除占用病床方式外的其他方式在医疗机构接受的治疗。

Outpatient - Services received while not an Inpatient in a Hospital, or other health care facility, or overnight

stay.

意外伤害：指以外来的、突发的、非本意的和非疾病的客观事件为直接且单独的原因致

使身体受到的伤害。

Accident - Any sudden and unforeseen event occurring during the Policy Year period, resulting in bodily

Injury, the cause or one of the causes of which is external to the victim’s own body and occurs beyond the victim’s

control.

等待期：指自本合同保险期间开始时间或者被保险人成为本合同的被保险人首日（以较

晚者为准）起保险人与投保人约定长度的期间。保险人对被保险人在此时间段内发生的对约

定病症的治疗和诊断费用不承担保险责任。

Waiting Period - Length of time agreed between the Insurer and the Policyholder, starting from the effective

date of this Policy or the first day that the Insured Person becomes an Insured Person under this Policy (whichever

is later), during which no benefit is payable by the Insurer even in the occurrence of an insured event.

医师：指具有医疗职业资格的任何人，包括内科医师、全科医师、专业医师、医学顾问，

以及其他任何在相应准许和训练范围内从事医疗服务的人员，不包括实习人员、在训人员。

Physician - Means any licensed person including physician, general practitioner, specialist physician, medical

adviser, and any other personnel who is allowed to provide medical services within the scope of that license. This

term does not include: (1) an intern; or (2) a person in training.

医学必需：指被保险人接受、使用或者服用的治疗、服务或者器械、药品符合以下条件：

Medically Necessary - When treatment, services, facilities or drugs which are provided to the Insured are:

（一）医师医嘱要求且对治疗被保险人疾病或者伤害合适且必需。

Consistent with the symptom, or diagnosis and treatment of the condition, disease or accidental Injury, and

prescribed by the Physician; and

（二）与接受治疗当地普遍接受的医疗专业实践标准一致。

Appropriate with regard to standards of accepted local professional practice; and

（三）非为了个人舒适或者为了被保险人父母、家庭、医师或者其他医疗提供方的方便。

Not solely for the Insured Person’s convenience, or for the convenience of the parents, the family, the

Physician or any other Provider of the Insured Person; and

（四）最恰当、合适水平。住院接受治疗时，无法以门诊的方式对相应疾病和症状提供

安全的医疗，且当前病症处于急性或者亚急性状态需要持续接受治疗、专业护理或者康复治

疗。主要出于接受慢性病治疗、长期看护、喘息照护、慢性病维持、协助从事日常生活活动

目的而住院的，不属医学必需。

The most appropriate supply or level of service, which can be provided. When applied to an Inpatient, it further

means that the medical symptoms or condition require that the services or supplies cannot be safely provided as an

Outpatient, and the patient’s medical status continues to require either acute or sub-acute levels of continuous

medical treatment, skilled nursing, or Rehabilitation services. Inpatient Hospital confinements primarily for purposes

of receiving non-acute, long term Custodial Care, chronic maintenance care, assistance with Activities of Daily

Living (ADL) are not eligible expenses.

（五）非患者学术教育或者职业培训的一部分或者与之相关。

Is not a part of or associated with the scholastic education or vocational training of the patient; and

（六）非试验性或者研究性。该治疗手段如获当地国家政府法律批准通过的，在当地国

家就诊手术发生的费用，且并未在责任免除中列出的。

The treatment approved by the law of the local government that is not Experimental or Investigative. It covers

the cost of the operation in the local country and is not listed in the “Exclusions”.

急性：指疾病病程短、病情相对严重（特别是严重急性病或者外伤），需要短期治疗。

Acute Care - Medically Necessary, short-term care for an Illness or Injury characterized by rapid onset, severe

symptoms, and brief duration, including any intense symptoms, such as severe pain.

亚急性：指病情具有急性病一些特征，处于急性和慢性之间。

Sub-Acute - Condition which is somewhat acute, falling between acute and chronic care, but with some acute

features.

康复治疗：指在既定的疗程内通过设计的维持项目改善病人身体状况，以免恶化并协助

康复。被保险人住院接受康复治疗的，保险人仅对处于急性或者亚急性阶段的病人住院承担

保险责任，且应经过医疗服务供应商批准。

Rehabilitation - Therapeutic services designed to improve a patient’s medical condition within a predetermined

time period through establishing a maintenance program designed to maintain the patient’s current condition, prevent

it from deteriorating and assist in recovery. Inpatient Rehabilitation is only covered during the Acute and Sub-Acute

recovery phase of treatment and only when authorized by the Medical Service Provider.

慢性病：指满足下列条件之一的伤害、疾病或者症状：

（一）持续接受三个月以上的医学必需的治疗；

（二）预期病程长久且无可合理预计的康复日期，可能复发、需要连续或者定期护理。

Chronic Condition - An Injury, Illness or condition, which may be expected to be of long duration without any

reasonably predictable date of termination, and which may be marked by recurrences requiring continuous or

periodic care as necessary; or which has had continued treatment for three months or more.

喘息照护：指出于减轻患慢性或者终末期疾病病人护理提供者负担目的，病人住院接受

的照料和护理。

Respite Care - Respite Care is Inpatient care for a chronically or terminally ill patient, for the sole purpose of

reducing the burden of the patient’s primary caregiver.

日常生活活动：指与个人生活自理基本行为相关的活动，包括但不限于行走、个人卫生、

睡眠、如厕（控制大小便的能力）、穿衣、做饭、进食、上下床。

Activities of Daily Living (ADL) - Activities of Daily Living are those activities normally associated with the

day-to-day fundamentals of personal self-care, including but not limited to: walking, personal hygiene, sleeping,

toilet/continence, dressing, cooking/feeding, and transferring (getting in and out of bed).

符合通常惯例水平的医疗费用：指以下两者中较低者：

Usual and Customary Charge - The lower of:

（一）提供相应医疗服务的医疗机构对该医疗服务通常收费水平。

a) The Provider’s usual charge for furnishing the treatment, service or supply;

（二）同一地区其他医疗机构对居住在同一地区的（以邮政编码为准）、病情性质和严

重程度类似的人员提供同样医疗服务的平均收费水平。若某医疗服务在当地区不常见或者仅

当地区少数医疗机构能够提供，保险人将参考下列因素确定通常惯例水平的医疗费用：治疗

复杂性，治疗必要的专业程度，必要的医疗专业类型，相应医疗机构提供的医疗服务范围和

种类，其他地区通常的收费水平。这里，地区指根据普遍认可的国际标准为取得类似医疗机

构或者类似医疗服务平均水平所必要的地域范围，可为一个城市、国家或者更广的地域。

or b) The charge determined by the Insurer to be the general rate charged by others who render or furnish such

treatments, services or supplies to persons: (1) who reside in the same area (zip code); and (2) whose Injury or Illness

is comparable in nature and severity. The Usual and Customary Charge for a treatment, service or supply that is

unusual, or not often provided in the area, or that is provided by only a small number of Providers in the area, will

be determined by the Insurer. The Insurer will consider such factors as: (1) complexity; (2) degree of skill needed;

(3) type of specialist required; (4) range of services or supplies provided by a facility; and (5) the prevailing charge

in other areas. The term “area” means a city, a county or any greater area, which is necessary to obtain a representative

cross section of similar institutions or similar treatment, based upon the formal international recognized standards.

护理：指用于在一定程度上治疗或者减缓病症，医师医嘱要求的、仅专业护士才能提供

的护理。

Nursing Care - defined as prescribed care that can only be provided by a registered professional Nurse which

is prescribed by the Physician to treat or ameliorate identified medical conditions on a limited basis.

放射治疗：指针对恶性肿瘤的放射治疗。放射治疗是使用各种不同能量的射线照射肿瘤

组织，以抑制和杀灭癌细胞为目的而进行的治疗。本合同所指的放疗为被保险人根据医嘱，

在医疗机构的专门科室进行的放疗。

Radiation therapy - Radiation treatment for malignant tumors. Radiotherapy is a treatment for the purpose of

inhibiting and killing cancer cells by irradiating tumor tissues with various energies. The radiotherapy referred to in

this Policy is a radiotherapy received by the Insured Person in the special department of Medical Service Provider

as Prescribed by the Physician.

化学治疗：指针对于恶性肿瘤的化学治疗。化学治疗是使用医学界公认的化疗药物以杀

死癌细胞、抑制癌细胞生长繁殖为目的而进行的治疗。本合同所指的化疗为被保险人根据医

嘱，在医疗机构进行的静脉注射化疗。

Chemotherapy - Chemotherapy for a malignant tumor. Chemotherapy is a medical treatment that is recognized

by the medical community to kill cancer cells and inhibit the growth and reproduction of cancer cells. The

chemotherapy referred to in this Policy is intravenous infusion chemotherapy received by the Insured in the Hospital

as Prescribed by the Physician.

肿瘤靶向疗法：指在细胞分子水平上，针对已经明确的致癌点来设计相应的靶向治疗药

物，利用具有一定特异性的载体，将药物或者其他杀伤肿瘤细胞的活性物质选择性地运送到

肿瘤部位攻击癌细胞的疗法。本合同所指的靶向治疗药物需符合法律、法规要求并经过国家

食品药品监督管理总局批准用于临床治疗。

Targeted therapy for tumor - a type of treatment which works at the molecular level and designs the

corresponding targeted therapy drugs against precisely identified carcinogenic point. It uses carrier of specificity to

selectively deliver the drugs or other active substances used to kill tumor cells to the tumor and attack cancer cells.

The targeted therapy drugs referred to in this Policy should comply with the laws and regulations and be approved

by China Food and Drug Administration for clinical treatment.

肿瘤免疫疗法：指应用免疫学原理和方法，使用肿瘤免疫治疗药物提高肿瘤细胞的免疫

原性和对效应细胞杀伤的敏感性，激发和增强机体抗肿瘤免疫应答，并应用免疫细胞和效应

分子输注宿主体内，协同机体免疫系统杀伤肿瘤，抑制肿瘤生长。本合同所指的肿瘤免疫疗

法需符合法律、法规要求并经过国家食品药品监督管理总局批准用于临床治疗。

Tumor immunotherapy - It refers to the application of immunology principle and method to increase the

immunogenicity of tumor cells and effect of cell damage sensitivity with tumor immunotherapy drug, stimulate and

facilitate the anti-tumor immune response, and application effects of immune cell and molecule infusion in host,

collaborative tumor of body’s immune system destruct tumor & inhabit tumor development. The tumor

immunotherapy referred to in this Policy should comply with the laws and regulations and be approved by China

Food and Drug Administration for clinical treatment.

肿瘤内分泌疗法：指针对于恶性肿瘤的内分泌疗法，用药物抑制激素生成和激素反应，

杀死癌细胞或抑制癌细胞的生长。本合同所指的内分泌疗法需符合法律、法规要求并经过国

家食品药品监督管理总局批准用于临床治疗。

Tumor endocrinotherapy - It refers to the endocrine therapy for malignant tumors, which uses drugs to inhibit

hormone production and hormone response, kill cancer cells or inhibit the growth of cancer cells. The tumor

endocrinotherapy referred to in this Policy should comply with the laws and regulations and be approved by China

Food and Drug Administration for clinical treatment.

物理治疗：指由具有相应医疗职业资格的专业医生实施的、应用人工物理因子（如光、

电、磁、声、温热、寒冷、力等）来治疗疾病，包括电疗、光疗、磁疗、热疗、冷疗、水疗，

超声波疗法以及功能训练和手法治疗，但不包括泥疗、蜡敷治疗、气泡浴与药物浸浴治疗。

Physical Therapy - The application of physical factors (such as light, electricity, magnetism, sound, heat, cold,

power, and so on) to treat diseases, including electrotherapy, light therapy, magnetic therapy, heat therapy and cold

therapy, hydrotherapy, and ultrasonic therapy, functional training and manipulation therapy; excluding mud therapy,

wax treatment, drug-bathing therapy, and bubble bath.

紧急医疗：指针对突然发生的、为避免严重终身伤害或者死亡须立即接受药物或者手术

治疗的症状，被保险人立即或者因不可抗力因素在症状发作后24小时内开始接受的相应医疗。

紧急医疗不包括：

Medical Emergency Services - Medical services provided in connection with an Emergency. Which is defined

as an injury or illness that is acute, poses an immediate risk to a person's life or long-term health and requires

immediate medical intervention, which the Insured Person shall secure after the onset of such condition (or as soon

thereafter as care can be made available, but in any case not any later than twenty-four (24) hours after the onset).

Emergency coverage absolutely excludes:

（一）以接受治疗为目的或者违背医嘱前往中国大陆以外地区期间发生的任何医疗；

Treatment which either arises from traveling against medical advice or is directly or indirectly aimed to

seek care or treatment outside the Mainland China.

（二）常规医疗；

Routine medical treatment;

（三）可以推迟至被保险人返回中国大陆后接受的医疗；

Treatment that could have been postponed until return from the area where only Emergency Coverage

is provided;

（四）被保险人事先计划好的治疗；

Treatment that has been planned in advance by the Insured Person;

（五）因被保险人已知或者应该知道的情形而发生的治疗；

Treatment arising from circumstances that could have been reasonably anticipated by the Insured

Person;

（六）妊娠、分娩及相关病症。

Maternity related treatments, including delivery and complications of pregnancy.

紧急：指突然发生的、会导致立即死亡或者长期健康问题的疾病或伤害。

Emergency - An injury or illness that is acute, poses an immediate risk to a person's life or long-term health.

重大疾病：本合同所规定的重大疾病仅包含以下种类：

Catastrophic Illnesses in this Policy include:

（一）心血管疾病——冠心病、先天性心脏病、心肌梗塞、主动脉瘤；

Cardiovascular diseases - Includes coronary artery disease, congenital heart disease, myocardial infarction, and

aortic aneurysm.

（二）神经疾病——脑卒中、脑动脉瘤、阿尔茨海默病、帕金森病、脊髓空洞症、多发

性硬化症；

Neurological conditions - Includes stroke, brain aneurysm, Alzheimer's disease, Parkinson's disease,

Syringomyelia, and Multiple Sclerosis.

（三）血液疾病——白血病、淋巴瘤、再生障碍性贫血、血小板减少性紫癜、血友病；

Hematologic diseases - Includes leukemia, lymphoma, aplastic anemia, ITP, and hemophilia.

（四）肺部疾病——慢性阻塞性肺病、原发性肺动脉高压；

Pulmonary diseases - Includes chronic obstructive pulmonary disease, and primary pulmonary hypertension.

（五）消化疾病——肝硬化、重症肝炎；

Digestive diseases - Includes liver cirrhosis, and severe hepatitis.

（六）自身免疫性疾病——系统性红斑狼疮、系统性硬皮病、获得性免疫缺陷综合症

（AIDS，艾滋病）、艾滋相关综合征（ARCS）和其他与HIV病毒相关的性传染病或者症状；

Autoimmune diseases - Includes systemic lupus erythematosus, systemic scleroderma, Acquired Immune

Deficiency Syndrome (AIDS), AIDS-related Complex Syndrome (ARCS), and all diseases caused by and/or related

to the HIV virus.

（七）其他——恶性肿瘤（含原位癌）、良性脑肿瘤、良性脊髓肿瘤、主要器官衰竭或

者移植、囊性纤维化、黑斑息肉病、Ⅲ度烧伤。

Others - Includes malignant tumor(including carcinoma in situ), benign brain tumor, benign spinal cord tumor,

major organ failure/transplants, cystic fibrosis, Peutz-Jeghers syndrome, and III-degree burns.

获得性免疫缺陷综合症（AIDS）：其定义以世界卫生组织制定的定义为准。如果在被保

险人的血液样本中发现艾滋病病毒或者其抗体，则认定被保险人己被艾滋病病毒感染或者患

艾滋病。

Acquired Immune Deficiency Syndrome (AIDS) – Defined as the definition by WHO. If the AIDS virus or

its antibodies are found in the blood samples of the Insured, the Insured is decided to have been infected with the

AIDS virus or suffering from AIDS.

每年实际住院日数：指保险期间内每次住院自入院之日起至出院前一日止期间的日数

之和，不包括未经办理出院手续擅自离院的日数。

Actual Number of Hospitalization Days per Year - Refers to the total number of hospitalization days from

the day of admission to the day before discharge during the Policy Period, excluding the number of days left the

hospital without going through discharge formalities.

针灸疗法：指针法和灸法的合称。针法是把毫针按一定穴位刺入患者体内，用捻、提等

手法来实施治疗。灸法是把燃烧着的艾绒按一定穴位熏灼皮肤，利用热的刺激实施治疗。针

灸治疗应当由具有相应资格的医师实施。

Acupuncture - Acupuncture therapy is treatment by stitching needles into the body of the patient at a certain

acupoint, twirling or lifting. Moxibustion therapy is the thermal simulation treatment by burning moxa at a certain

acupoint of the skin. Acupuncture and moxibustion treatment should be carried out by a qualified physician.

顺势疗法：指一种通过小剂量药物治疗以使病人症状渐渐接近常人的治疗方法，比如通

过给予小剂量的放松剂治疗腹泻。

Homeopathy - A system of alternative medicine that seeks to treat patients by administering small doses of

medicines that would bring on symptoms similar to those of the patient in a healthy person. For example, the

homeopathic treatment for diarrhea would be a miniscule amount of a laxative.

中草药：指中医理论指导下应用的天然药物及其制品，包括中药材和中药饮片,但不含

健康滋补类中草药，健康滋补类中草药包括但不限于：

Traditional Chinese Medicine - Natural medicines and their products under the guidance of theory of

Traditional Chinese Medicine. Includes Chinese herbal medicine, pieces of Chinese Medicine. Excludes medicines

for general health improvement, including but not limited to:

（一）单味或复方均不予支付费用的中药饮片及药材：

鹿茸、猴枣、狗宝、海马、海龙、玛瑙、玳瑁、冬虫夏草、马宝、牛黄、珊瑚、麝香、

羚羊角尖粉、犀角、燕窝、人参（生晒参除外），以及各种可以药用的动物脏器（鸡内金除

外）和胎、鞭、尾、筋、骨。

Traditional Chinese Medicines with a pure form or within Chinese medicines compound Hairy antler,

monkey bezoars, Canis familiaris, Seamaster, Pipe fish, Agate, hawksbill, Chinese caterpillar fungus, Horse

bezoars, Bezoars, Coral, Moschus, Cornu Saigae Tataricae apex powder, Cornu Rhinocerotis, Birderotis,

Birdder, Cornn, Cornn Cornrnr, Cornr fungus, Horse bezoars, Bezoars, Coral, Moschus, Corcorneum) which

can be used as medicines such as placenta, penis, tail, tendon, bone, etc.

（二）单味使用不予支付费用的中药饮片及药材：

阿胶、阿胶珠、鹿角胶、鳖甲胶、三七、龟角胶、龟鹿二仙胶、龟板胶、藏红花、生晒

参、羚羊角粉。

Traditional Chinese Medicines with a pure form Colla Corii Asini, Colla Corii Asini beads, Deer-horn

glue, Turtle shell Glue, Pseudo-ginseng, Turtle Angle glue, Guilu erxian glue, Tortoise-plastron glue, Safflower,

Sun-cured ginseng, Antelope horn powder.

（三）以上所列药品包括生药及炮制后的饮片及药材、中药敷贴、中药熏蒸。

Wine soaked with above Traditional Chinese Medicine and their cut crude drugs, processing pieces,

processing herbs, herbal fumigation and acupressure adhesive plasters.

既往症：指在保险人对其保险责任生效前被保险人已就此接受诊断、医学咨询或者治疗，

或者服用药物，或者显现症状的疾病或者损伤。包括以下任何情形：

Pre-existing Condition - Means any Illness or Injury, for which an Insured Person received any diagnosis,

medical advice or treatment, or had taken any prescribed drug, or where distinct symptoms were evident prior to the

Effective Date. It includes the following conditions:

（一）本合同生效前，医生已有明确诊断，长期治疗未间断；

a. The doctor has made a definite diagnosis and the long-term treatment has not been interrupted;

（二）本合同生效前，医生已有明确诊断，治疗后症状未完全消失，有间断用药情况；

b. The doctor has made a definite diagnosis, but the symptoms have not completely disappeared after treatment,

and there is intermittent treatment;

（三）本合同生效前，未经医生诊断和治疗，但症状或者体征明显且持续存在，以普通

人医学常识应当知晓。

c. It has not been diagnosed and treated by a doctor, but the symptoms which are evident and persistent should

be known with common medical knowledge.

专业护士：指国家护士注册机构护士登记名册中登记在案的护士。

Skilled Nurse - A person licensed as a Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.) by the

appropriate licensing authority in areas in which he or she practices nursing.

专业护士家庭护理:指曾住院接受治疗的病人出院后随即在其家中接受医师要求的、医

学必需的专业护士护理。

Home Health Nursing - Refers to Medically Necessary home nursing by a Skilled Nurse immediately

following treatment as an inpatient on Physician recommendation.

临终关怀：指病人被诊断患终末期疾病后，该病人接受具有相应资质的临终关怀机构提

供的、由专业人员和志愿者组成的跨学科队伍在医学指导下实施的姑息性、支持性医护。

Hospice Care - A program approved by the Medical Service Provider to provide palliative and supportive

services to terminally ill persons. Services must be provided by a recognized hospice, and a medically supervised

interdisciplinary team of professionals and volunteers.

临终关怀机构：指提供临终关怀的机构，该机构应满足下列全部条件：

Hospice – An agency which provides hospice care to a terminally ill person and which meets all of the following

conditions:

（一）取得了政府相关部门的批准；

Has obtained any required state or governmental license or Certificate of Need;

（二）二十四小时提供服务；

Provides service twenty-four (24) hours-a-day;

（三）有医师直接管理和监控；

Is under the direct supervision of a Physician;

（四）有注册护士指挥、协调护理服务；

Has a Nurse coordinator who is a Registered Nurse (R.N.) or a Licensed Practical Nurse (L.P.N.);

（五）被批准从事社会服务指导和协调；

Has a duly licensed social service coordinator;

（六）主要目的为提供临终关怀服务；

Has as its primary purpose the provision of Hospice services;

（七）有全职管理人员；

Has a full-time administrator;

（八）保存了所提供服务的全部书面记录。

Maintains written records of services provided to the patient.

监护：包括以下情形：

Custodial Care - Includes:

（一）对其治疗医师认为已达到最大限度康复但仍存在身体或者智力残疾人员提供的床

位、护理等服务；

The provision of room and board, nursing care, or such other care which is provided to an individual who is

mentally or physically disabled and who, as determined by the individual’s attending Physician, has reached the

maximum level of recovery; and

（二）对预计医疗或者手术已不能使其在医疗机构外生活人员提供的床位、护理等服务；

In the case of an institutionalized person, room and board, nursing care or such other care which is provided to

an individual for whom it cannot reasonably be expected that medical or surgical treatment will enable him to live

outside an institution; and

（三）修养疗法、喘息照护，以及家庭成员提供的家庭看护。

Rest cures, Respite Care and home care provided by family members.

生育控制：包括但不限于输精管切除术和绝育术，男性或者女性绝育恢复手术，伟哥，

以及其他用于提高性功能的药物费。

Birth Control - Includes but not limited to Vasectomy and sterilization, any expenses for their recovery,

“Viagra”, other sexual enhancement drugs and their respective generic equivalents.

住宅设备：指为满足日常生活活动所需的安置于住宅室内的器具。包括但不限于住宅室

内的空调、湿度调节器、除湿器和空气净化器、太阳能或者加热灯、加热垫、坐浴盆、盥洗

凳、浴缸凳、桑拿浴、升降机、涡流按摩浴、健身器材，以及其他类似设备。

Residential Facilities - Refers to the indoor facilities in order to meet the needs of daily living activities,

including not limited to indoor air conditioners, humidifiers, dehumidifiers, and purifiers (air cleaners), sun or heat

lamps, heating pads, bidets, toilet seats, bathtub seats, sauna baths, elevators, whirlpool baths, exercise equipment,

and similar items.

悲伤辅导和悲伤治疗：指由具有相应资格的咨询师、精神科医师、心理医师、牧师针对

家人逝世或者终末期病人的治疗。

Bereavement Counseling - Counseling of a terminally ill or deceased member’s family by a licensed counselor,

psychiatrist, psychologist, or pastor.

注意力缺陷症：指一种生物学方面改变所致的病理状态，症状表现为：注意力涣散、活

动过多、冲动任性等。

Attention Deficit Disorder (ADD) - A biologically based condition causing a persistent pattern of difficulties

resulting in one or more of the following behaviors: inattention; hyperactivity; impulsivity.

注意缺陷多动障碍：指一种常见的儿童精神障碍，主要表现为超出了儿童年龄和发育正

常范围的注意力集中困难、活动过多、冲动任性等症状。

Attention Deficit Hyperactivity Disorder (ADHD) - A common mental disorder in children with

inattentiveness, over-activity, impulsivity, or some combination of these. For these problems to be diagnosed as

ADHD, they must be out of the normal range for the child's age and development.

先天性疾病和症状：指由于基因因素、先天性新陈代谢异常或者其他因素导致的、出生

时即存在的遗传性疾病和症状、出生缺陷、身体残疾、智障等发育不完全正常的疾病和症状，

这些疾病和症状可能在出生时显现或者在出生后逐步显现。

Congenital Condition - Any heredity condition, birth defect, physical anomaly and/or any other deviation from

normal development present at birth, which may or may not be apparent at that time. These deviations include but

are not limited to, genetic factors, inborn errors of metabolism or other factors.

高风险运动：指各种危险性较高、技巧与体能需求较高的运动项目。包括：滑翔翼、跳

伞、海拔六千米以上的户外运动、十八米深以上的潜水、悬崖跳水、徒步穿越无人区（沙漠、

戈壁等）、远海漂流、蹦极、野外攀岩、跑酷等。

High Risk Sports or Extreme Sports - Sports and recreational activities which require high level skill, a degree

of risk or physical stamina, including but not limited to: hang-gliding, parachuting, outdoor activities at 6000 meters

above sea level, scuba diving below 18 meters, cliff diving, hiking through uninhabited places (such as a desert,

gobi), offshore rafting, bungee jumping, outdoor rock climbing, parkour.

战争：包括入侵、内战、敌对国家行为、叛乱、革命、武装叛变、武装夺权、战争武器

爆炸等。类似战争的行为视为战争。

War - Including invasion, civil war, rebellion, revolution, armed seizing power, explosion of war weapons, etc.

Warlike operations are regarded as war.

恐怖活动：指恐怖主义性质的下列行为：

Terrorist Activities - Refers to the following actions:

（一）组织、策划、准备实施、实施造成或者意图造成人员伤亡、重大财产损失、公共

设施损坏、社会秩序混乱等严重社会危害的活动的；

1) Organizing, planning, preparing, implementing, or carrying out activities that cause or are intended to

endanger society, such as casualties, major property damage, damage to public facilities, social disorder;

（二）宣扬恐怖主义，煽动实施恐怖活动，或者非法持有宣扬恐怖主义的物品，强制他

人在公共场所穿戴宣扬恐怖主义的服饰、标志的；

2) Promoting and inciting the implementation, or illegally holding articles promoting Terrorist Activities, and

forcing others to wear clothes and signs promoting Terrorist Activities in public places;

（三）组织、领导、参加恐怖活动组织的；

3) Organizing, leading, or participating in terrorist activities;

（四）为恐怖活动组织、恐怖活动人员、实施恐怖活动或者恐怖活动培训提供信息、资

金、物资、劳务、技术、场所等支持、协助、便利的；

4) Providing support, assistance, and conveniences to terrorist organizations, or terrorist personnel

implementing or training for terrorist activities such as information, funds, materials, labor, technology, and shelter;

（五）其他恐怖活动。

5) Other terrorist activities.

保险金申请人：指受益人、被保险人的继承人或者依法享有保险金请求权的其他人。

Claimant ‐ means the beneficiary, the successor of the Insured Person, or the other eligible person who has

the right to claim benefits in accordance with the law.

不可抗力：指不能预见、不能避免并不能克服的客观情况。

Force Majeure - Force impossible to foresee, avoid or overcome by objective situation.

现金价值：指本合同保险单所具有的价值，通常体现在解除合同时，根据精算原理计算

的，由保险人退还的那部分金额。现金价值=净保费×[1-m/n]。其中，m为已生效天数，n为

保险期间的天数，已经过天数不足一天的，按一天计算。净保费=保费×（1-25%）。

Cash Value - The value of the Insurance Policy, usually refers to the amount calculated according to actuarial

principles and refunded by the insurer upon termination of the contract. Unused premium = Net premium * [1‐ (the

number of days passed for insurance liability to the Insured / total number of days during the Policy Period)]. The

number of days passed which is less than one day shall be calculated as one day. Net premium = premium *(1-25%).