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Product Benefits Summary
If an injury arising from accident causes the insured member to require medical treatment by physician or nurse within 52 weeks from the date of the accident, the company will pay for the medical expense based on the actual payment after deducting the reimbursement from other source (if any).
The maximum benefit per accident shall not exceed the sum insured per accident
Product Features Summary
| Insured’s age | From 15 to 70 years old |
| Sum assured | From $50 |
| Policy term | 1 year |
| Premium payment term | 1 year |
| Premium payment mode | Annually, semi-annually, quarterly and monthly |
Product Detail
SMILE Group Medical Expense Benefit 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.
1. Definitions
“Medical Expense” means fee for room and board, surgery and anesthetics, medication and other hospital expenses, operating room, laboratory examination and physician’s consultation.
“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 the physician’s diagnosis and recommendation under the medical standard and for a reasonable period considering the condition of each 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” 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.
“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 descendant.
“Nurse” means a person with legal nursing license.
“Injury” means bodily injury as a direct result from an accident that occurs independently and distinct from other causes.
“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 any 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.
2. Coverage
If an injury arising from accident causes the Insured Member to require medical treatment by physician or nurse within 52 weeks from the date of the accident, the Company shall indemnify for a reasonable and appropriate expenses incurred from the treatment as considered a medical necessity based on generally accepted medical practice for the inpatient room and board, resuscitation room expense, medical fees and medical supply fees with a maximum of the sum assured per accident indicated in the Policy Schedule.
If the Insured Member has already been reimbursed from social welfare or any other fringe benefits or other insurance, the Company shall be responsible only for the cost of medical treatment that has not yet been reimbursed.
3. Medical Expense Benefit Rider Claim
The Insured Member shall deliver, at their own expense, the following evidence to the Company within 30 days from the day the Insured Member leaves the hospital, infirmary or clinic.
1. The Company’s Claim Form
2. Physician Report indicates the symptom, diagnosis, and treatment
3. Original copy of receipt showing a list of actual expenses or the actual expense report and receipt
Receipt showing a list of expenses must be the original copy and the Company will return such receipt with indication of actual payment made to the Insured Member, so the Insured Member could claim the remaining balance from other sources. However, if the Insured Member had been previously reimbursed from other sources, the Insured Member shall submit a copy of receipt with indication of actual payment already disbursed to claim the remaining balance.
4. 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 71 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.
5. Limitation of Group Medical Expense Benefit Rider
Group Medical Expense rider shall not cover the following:
1. Special nurse expense, supporters (except crutches), wheelchair, prosthesis, Alternative Medicine, and acupuncture; or
2. Dental treatment, root canal treatment, false teeth changing or insertion, dental crown, and prosthetics, unless incurred within 7 days after accident.