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Product Benefits Summary
- For this rider benefit, the Insured Member will get the daily benefit of Group Hospital Daily Benefits Rider in the case the Insured Member gets an injury or illness and admits as an inpatient of a hospital for at least 6 consecutive hours, where the daily benefit of each hospital confinement arising from one injury or illness does not exceed 30 days.
- The Insured Member will also get an extra 100% of daily benefit in the case that the Insured Member is admitted as an inpatient to the Intensive Care Unit (ICU) of a hospital, where the daily benefit of each hospital confinement arising from one injury or illness does not exceed 7 days.
Product Features Summary
| Insured’s age | From 15 to 65 years old |
| Sum assured | From $10 |
| Policy term | 1 year |
| Premium payment term | 1 year |
| Premium payment mode | Annually, semi-annually, quarterly and monthly |
Product Detail
SMILE Group Hospital Daily Benefits is a rider that is attached to the group based policy. If there are any conflicts between the group based policy and this rider, the content in this rider shall prevail.
I. Coverage
If the Insured Member experiences accidental injury or becomes ill, which causes the Insured Member to be admitted as an inpatient or requires physician’s advice in diagnosis process while this rider is still in forced and after the 30 days waiting period has ended for any illness causes; Company would pay benefits as follows:
1.1 In the case that an Insured Member is injured or ill, which causes the Insured Member to be admitted as an inpatient of a hospital as required by its medical necessity for at least 6 consecutive hours; the Company shall pay daily benefits as set in Group Insurance Quotation to the Insured Member, where the daily benefit of each hospital confinement arising from one injury or illness at once time does not exceed 30 days.
1.2. In the case that an Insured Member needing to be admitted as an inpatient in the Intensive Care Unit (ICU) of a hospital, the Company would pay an extra 100% of daily benefits as set in the Group Insurance Quotation, where the daily benefit of each hospital confinement arising from one injury or illness does not exceed 7 days.
The total benefit payout per day in total of No. 1.1 and No. 1.2 shall not exceed beyond 200% of the stated daily benefit.
The maximum length of stay as an inpatient for No. 1.1 and No. 1.2 per one hospital confinement shall not exceed 30 days.
Moreover, any benefit payouts shall be made after the deduction of all unpaid loans and any other obligations.
II. Definitions
“Illness” means the symptom, abnormality, sickness or disease caused to the Insured Member.
“Injury” means an act that damage or hurts which occurs to Insured Member due to accident to the extent that needs to be admitted in a hospital for medical treatment as an inpatient.
“Accident” means sudden event, caused by external factor with a result that is not the intention or determination of the Insured Member.
“Physician” means contemporary physician who holds medical certificate recognized by Ministry of Health and is legally registered with the Medical Council of Cambodia to practice medical treatments or surgical services who is not the Insured Member, the Insured Member’s spouse or descendent.
“Medical Fees” means expenses that a hospital charges in exchange of medical service while the Insured Member is admitted as inpatient.
“Inpatient” means the Insured Member is admitted in a hospital for at least 6 consecutive hours and registered as inpatient of the hospital registration, which is as a result of physician’s diagnosis and recommendation under the medical standard and for a reasonable period considering the condition of each injury or illness.
“Hospital” means legally constituted establishment which operates pursuant to the laws of the country in which it is based and registered as hospital and which:
1. It can provide care and treatment of sick and injured persons on a resident inpatient basis;
2. It has facilities for diagnosis, treatment and major surgery;
3. It can provide full time nursing service;
4. It is under the supervision of a registered practitioner;
5. It is not primarily a clinic, a place for custodial care of, the aged, persons with mental disorders, alcoholics or drug addicts, a nursing, rest or convalescent home.
“Medical Standard” means international medical guidelines or practices that results in an appropriate treatment plan for patient as identified medical necessity that also matches the conclusion taken from record on injury, detection, examination results, or others (if any).
“Medical Necessity” means medical services with following conditions:
1. Justified as reasonable based on its diagnosis and treatment according to the Insured Member’s condition of injury or illness;
2. Includes clear medical indicator based on modern medical standard;
3. Must not be for convenient purposes of one party, either the Insured Member, Insured Member’s family or the medical service provider; and
4. Must be an appropriate medical treatment based on clinical standard of care and as necessary to the Insured Member’s condition of injury or illness.
“Alternative Medicine” means medical diagnosis or prevention based on Khmer traditional medicine, Khmer indigenous medicine, Chinese traditional medicine or any other methods rather than modern medicine.
“Hospital Confinement” means an admission in hospital for treatment as inpatient. This also includes any number of hospital confinements arising from one same cause or disease or any complications from such cause or disease, and this hospital confinement shall be considered as only one hospital confinement if the gap of each admission as inpatient shall not be more than 90 days from the latest discharge day.
“AIDS” means Acquired Immune Deficiency Syndrome and this also covers the symptomatic infection, Malignant Neoplasm, or any other infections or illnesses caused, according to the blood test with positive result, by HIV (Human Immune Deficiency Virus), the symptomatic infection includes, but not limited to, the Pneumocystis Carinii Pneumonia, Organism Or Chronic Enteritis, Virus and/or Disseminated Fungi Infection, Malignant Neoplasm. It also includes, but not limited to, Kaposi’s Sarcoma, Central Nervous System Lymphoma and/or any other critical illness known in modern medical that it was caused by Acquired Immune Deficiency Syndrome or was caused someone a sudden death, an illness or disability. AIDS includes HIV (Human Immunodeficiency Virus), Encephalopathy (Dementia) and virus prevalence.
III. General Provisions
3.1 Notification of Injury or Illness
The Policyholder or the Insured Member, whichever the case may be, shall notify the Company as soon as possible on the injury or illness that could cause claim for coverage under this rider, unless it can be proved that there is a reasonable cause for any delay in the notification.
3.2 Delivery of Claim Evidence
The Policyholder or Insured Member must deliver the evidence within 30 days to the Company after the day the Insured Member leaves the hospital, where copy of receipt is acceptable in claim process.
Failure to deliver the evidence within stated timeline would not result in loss of claim rights, if it could be proved to have reasonable cause for such absence; however, the evidence shall be delivered as soon as possible. The Policyholder or Insured Member must pay for any expenses incurred from obtaining such evidence.
3.3 Medical Examination
Within a reasonable period, the Company holds a right to inspect the medical records of the Insured Member as necessary for claim assessment. If the Insured Member denies giving consent to the Company for the inspection as part of claim underwriting process, the Company could deny providing the Insured Member the coverage.
3.4 Benefit Payout
All benefits in this rider shall be paid to the Insured Member and any payouts are considered as legal release of liabilities for the Company. In case the Insured Member dies during or after hospitalization, the Company shall pay this rider benefit to the beneficiary as stated in the group based policy.
3.5 Termination of the Rider
This rider shall be terminated upon one of the following incurrence:
1. When the group based policy that this rider is attached to is no longer inforce; or
2. If there is no premium payment of this Rider within the grace period of 31 days; or
3. On the policy anniversary date of the group insurance policy that this Rider is attached to, which is applicable only to the Insured Member who attains the age of 66 years old.
The termination of this rider shall have no effect to any claim rights existing prior to such termination. If the Company receives any premium after the day of termination; it would not bind the Company to any liabilities but to refund such premium.
3.6 Fraud
If any claim under this rider shall be in any respect fraudulent or if any fraudulent means or devices shall be used to obtain the Benefit under this rider, the Company shall have no liability in respect of such claim.
3.7 Rider Cancellation
The company may cancel this rider by advance notice in writing of not less than 30-day, if it shows obvious evidence that the Policyholder or the Insured Member conducts fraud to make use of the benefits under this rider either for the Insured Member or others. In this case, the Company shall return premium to the Policyholder or the Insured Member only for the part of coverage that has not been provided.
The Policyholder must give a written notice 10-day prior to the cancellation date specified in the letter to the Company if the Policyholder wishes to cancel the insurance before expiry date. The cancellation will be effective on the date specified in the letter. Based on reasonable grounds, the Company will refund the premium to the Policyholder or the Insured Member only for the part of coverage that has not been provided.
3.8 Condition Precedent
The company shall not be liable to pay any compensation under this rider unless the Insured Member shall have complied properly with the insurance contract and condition of this rider.
3.9 Waiting Period
a. The Company shall not make any benefit payout according to this rider for any illnesses incurred during the first 30 days after this rider become effective or reinstate, whichever case may occur last; or
b. The Company shall not make any benefit payout according to this rider for the following illnesses incurred during the first 365 days after this rider becomes effective or reinstated, whichever case may occur last:
1. All kinds of benign or malignant tumors
2. Hemorrhoids
3. Anal fistula
4. Hydroceles
5. Any kind of hernia
6. Hypertension or cardiovascular disease
7. Calculi of kidney or urethra
8. Hysterectomy
9. Cataracts
10. Prolapsed intervertebral disc
11. Cholecystitis
12. Sinus conditions or abnormalities of nasal passages, septum, or turbinated
13. Endometriosis
14. Thyroid dysfunction
15. Epilepsy
16. Tuberculosis
17. Gastric or duodenal ulcer
18. Varicoceles
19. Hallux valgus
20. Uterine fibroids
21. Tonsils and Adenoids Disease
3.10 Exclusions
This rider does not cover any expenses incurred from hospital treatment or any damages incurred from injuries or illnesses (including any complications), symptoms or abnormalities arising from:
1. Chronic decease, illnesses or injuries that was not treated prior to the contract is signed, congenital anomalies, or pervasive development disorders or genetic disorders; or
2. Cosmetic surgery or any other treatments for skin beauty purposes, pimple and blemish treatment, dandruff and hair fall treatment, or weight control, or elective surgeries, unless a skin grafting arising from accident that this rider covers; or
3. Pregnancy, miscarriage, abortion, childbirth, any pregnancy complications, infertility resolution (including diagnosis and treatment), sterilization or birth control; or
4. AIDS, venereal disease, or sexually transmitted diseases; or
5. Anti-aging treatment or prevention by consuming drugs or substances, pharmacology for skeletal disorders due to aging, male or female sexual malfunction, any sexual disorder treatments and sexual reassignment surgery; or
6. General or regular medical examinations, individual request for admission in hospital or clinic, individual request for surgery, rest recovery or rest cure, any diagnosis other than the original cause of treatment, diagnosis of injury or illnesses, any diagnosis considered not a medical necessary or not required by medical standard, and exclusive nurse service fees; or
7. Ophthalmic disorders diagnosis and treatment, LASIK, expenses on vision aids or treatment; or
8. Oral check, treatment or surgery, including denture, dental crown, root cannel treatment, dental filling, orthodontic, tooth scaling, dental extraction, dental implants unless necessitated by an accidental injury; however for such incident the coverage shall not be provided for the false tooth/teeth, dental crown and root cannel treatment or dental implants; or
9. Treatment or rehabilitation for narcotic drug, cigarette, alcohol or any psychotropic substances addiction; or
10. Diagnosis and treatment for mental illness or disorder, psychiatric or psychological illness, or behavior disorders or personality disorders, Attention Deficit Hyperactivity Disorder (ADHD), autism, stress, eating disorder; or Anxiety; or
11. Any types of treatment under experiment, treatment or diagnosis on obstructive sleep apnea symptom or illness, treatment or diagnosis on sleep disorder and snoring; or
12. Diagnosis and treatment other than modern medicine, including alternative medicine; or
13. Expenses incurred from the diagnosis and treatment that the Insured Member is acting as his/her own physician, and also such expenses that the Insured Member’s parent, spouse, or child is acting as the physician; or
14. Suicide or attempted suicide, self-inflicted injury, whether sane or insane within two years after this rider Effective Date or the effective date of any reinstatement of this rider, whichever is later. This shall include an incident when the Insured Member eat, drink or inject drug or toxic substance into one’s body in excess of the doctor’s instruction; or
15. Using drugs or stimulators, abusively using alcohol or driving vehicles under the influence of alcohol as defined in the current laws and regulations. The influence of alcohol means the blood test shows alcohol level from 150 milligram or more; or
16. Injuries arising while participating in a quarrel or causing the quarrel; or
17. Injuries arising under an incident where the Insured Member intentionally committed a serious crime or while under arrest or absconding; or
18. Injuries arising while engaging in all boat or automobile speed racing, horse racing, skiing of any kind including jet-skiing, skating sport, boxing of any kind, parachuting (except for life saving purposes), ballooning, hang gliding, bungee-jumping, underwater activities that involves the use of breathing apparatus; or
19. Injuries arising while serving as a soldier, policeman or a volunteer; or
20. Any types of operation in a war or suppression, declared or undeclared war, aggression or an act of foreign enemy, a warlike action; civil war, rebellion, insurgent, riot, strike, insurrection, revolution, coup d’état, declaration of martial law implementation, or any other situations that causes the implementation of martial law to continue; or
21. Any Pre-existing Conditions: which mean:
(i) Which existed or was existing, prior to the relevant Policy Date or reinstatement date, whichever is later;
(ii) Where its cause existed or was existing, prior to the relevant Policy Date or reinstatement date, whichever is later;
(iii) Where the Life Insured Member had knowledge, signs or symptoms of the injury, sickness, disease or illness, prior to the relevant Policy Date or reinstatement date, whichever is later;
(iv) Where any laboratory test or investigation showed the likely presence of the injury, sickness, disease or illness, prior to the relevant Policy Date or reinstatement date, whichever is later.