axa affin general insurance berhad - oshrshr.zendesk.com · diagnostic lab / x - ray procedure ......
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AXA Affin
General Insurance Berhad
OS HRS SDN BHD
Policy Number : 04326480
Period of Insurance : 01/03/2018 to 28/02/2019
DISCLAIMER: This document is confidential; its contents do not constitute a commitment by AXA Affin General Insurance
Berhad except where provided for in a written agreement between you and AXA Affin General Insurance Berhad. Any
unauthorized disclosure, use or dissemination, either whole or partial, is prohibited. If you are not the intended recipient this
document please notify the sender immediately.
Contents
2
1. Policy Coverage – Outpatient
2. Outpatient Workflow
3. Outpatient Policy Exclusions
4. Policy Coverage – Inpatient
5. Admission & Discharge Workflow
6. Panel Hospitals
7. Inpatient Policy Exclusions
8. Reimbursement Process
9. Q & A
Schedule of Benefits – Outpatient
SCHEDULE OF BENEFITS PLAN
(RM)
1
OUTPATIENT GP TREATMENT
at AXA Panel Clinics
Routine Consultation
Medication
Injection
Diagnostic Lab / X - Ray Procedure
Out-patient Surgical Procedures
Limit per visit Unlimited
Number of Visit per year per insured Unlimited
Copayment Nil
Overseas Treatment (Limit per visit- RM) 50
2
OUTPATIENT SPECIALIST TREATMENT
With Panel GP Referral
Consultation
Medication
Injection
Diagnostic Lab / X - Ray Procedure
Out-patient Surgical Procedures
Limit per visit Unlimited
Number of Visit per year per insured Unlimited
Copayment Nil
Limit per Annum 1,200
Overseas Treatment (Limit per visit- RM)150
(Without GP Referral)
This includes long term medication for below Chronic Illnesses :
Chronic illnesses such as Diabetes, High Blood Pressure, Asthma, Hepatitis B and C
Carriers, nerve disorders or degenerative diseases, endometriosis, transverse myelitis
and conditions arising there from or associated therewith.
Subject to following:
All insured members are to seek treatment at panel GP
Drugs prescribed for use within one (1) month after treatment from GP
Outpatient (Clinical) Benefits
Any plan enquiry related to medical coverage, please contact MiCare at
Hotline : 1 300 88 9979
Email : [email protected]
NEW DECAL
Cashless Medical Card
Clinic nurse verifies name
against on-line real time
MiCARE system
Patient enjoys Cashless Visit
by collecting medication
without any payment.
Patient signs
Medical Record of
Attendance
Patient arrives at clinic,
present Medical Card
Patient seeks
consultation
Caution:
Patient is required to make
payment when the claim has
exceeded the entitlement (if any)
Outpatient GP Flow Chart
Before the appointment, call
the 24/7 Call Centre for a
Guarantee Letter. Fax over
the referral letter
Alternatively, the hospital
can contact us with
Outpatient Claim Form
Our Call Center validates
& authenticate info, issues
Guarantee Letter within 1
hour upon receipt of
relevant documents
Patient obtained
appointment date for
Specialist visit upon receipt
of Referral Letter from Panel
Clinic
Patient seeks
consultation
Outpatient specialist
clinic/hospital receives
Guarantee Letters
Patient enjoys Cashless Visit by
collecting medication without
any payment required. However,
patient may be required to pay
for uncovered charges.
Outpatient SP Flow Chart - Cashless
• More than one (1) Outpatient Consultation per day to a General Practitioner or
Specialist.
• Vitamins, Food Supplement, Herbal Cures, Anti Obesity/Weight Reducing
Agents including off the counter medications.
• Investigation and Treatment of sleep and snoring disorders.
• Private nursing care and house calls by doctors for any reasons.
• Hormone therapy
• Contraceptive medications and devices, sterilisation procedures, Treatment for
complications, reversal of such procedures and the work up or Treatment of
sexual dysfunction or infertility.
• Any circumcision unless Medically Necessary.
Policy Exclusions
• Investigation and Treatment relating to pregnancy including prenatal,
childbirth, postnatal and all complications arising therefrom.
• Conditions related to sexually transmitted Disease, AIDS and AIDS
Related Complex or its sequel.
• Preventive Vaccinations / Immunisations except for the following that
are applicable to eligible Children only (subject to Outpatient Benefit
limit, if any):
Policy Exclusions
BCG (booster);
Hepatitis B (infants up to 1 year old);
Triple Antigen & TetrAct Hib (infants up to 1 year old);
Double Antigen (booster), including Oral Polio;
MMR;
Rubella
Note: This list is non-exhaustive. Please refer to the policy contract for the terms and conditions under this policy.
Schedule of Benefits – Inpatient
TABLE OF BENEFITS PLAN RB350 PLAN RB200
1 Hospital Room & Board (Daily max up to 180 days) 350 200
2 Intensive Care Unit (Daily max up 30 days)
Full Reimbursement subject to Overall Limit provided the
charges are within the recommendation of the MMA
Guidelines and Reasonable and Customary Charges
3 Hospital Supplies and Services
4 Surgeon Fee
5 Anaesthetist Fee
6 Operating Theatre Charges
7Daily In-Hospital Physician’s Visit
(Max. 180 days)
8Pre-Hospital Diagnostic Tests
(within 60 days before hospital confinement)
9Pre-Hospitalisation Specialist Consultation
(within 60 days before hospital confinement)
10Second Surgical Opinion
(within 60 days before hospital confinement)
11Post-Hospitalisation Treatment
(within 60 days from hospital discharge)
12Emergency Accidental Outpatient Treatment
(within 24 hours after the accident & follow-up up to 60 days)
13Accidental Dental Treatment
(within 24 hours after the accident & follow-up up to 14 days)
14 Daycare Procedure
15 Ambulance Charges (by road)
16 Annual Outpatient Cancer Treatment
17 Annual Outpatient Kidney Dialysis Treatment
18 Goods and Services Tax
19 Government Hospital Daily Cash Allowance (Max. 180 days) 200 100
20 Emergency Sickness Treatment (10pm - 8am) 100 100
21 Medical Report Fee Reimbursement 80 80
OVERALL ANNUAL LIMIT 80,000 40,000
22 Funeral Expenses 10,000 10,000
For emergency, please proceed to Emergency Department
in the hospital. Hospital will stablised member before going
through normal admission procedure.
a) Non Elective / Non Pre-Planned:
Member to produce IC, Admission
Letter & Medical Card to the
admission counter
b) Elective / Pre-Planned:
Member to present the IC,
Medical Card & Admission Letter
to the admission counter.
(Please inform on the actual
admission date and request for
Pre-Planned arrangement)
a) Hospital verifies card and name
via our 24x7 call center / web-
system
b) Hospital will assist to prepare
relevant documents & medical
reports
Hospital faxes relevant
documents with Admission
Request Form
a) Call Center validates & authenticate info,
issues Guarantee Letter or Decline
Letter within 1 hour upon receipt of
relevant documents
b) Call Centre validates info, issues Pre-
Approved GL or Decline Letter within 1
hour upon receipt of relevant
documents. Member to contact Call
Centre / Hospital on the status of
Guarantee Letter.
a) Member gets admitted into hospital
b) Member proceed to the admission counter
and pre-approved GL is ready for
member’s admission
213
4
Admission to Panel Hospital
Patient ready to be
discharged
Hospital prepares
itemized bills and gathers
all relevant reports
Hospital faxes
itemize bills and all
relevant reports
Our Call Center validates,
audits & processes bills from
hospital, issues Final
Guarantee Letter within 1
hour upon receipt of full
documents from hospital
Hospital receives
Final Guarantee
Patient pays for
uncovered charges
(if any)
Patient
discharged
Discharge from Panel Hospital
Examples of non-covered items:
• Diagnostics tests that are not related to the disability during the admission
• Extra food
• Admission kit / inpatient kit / discharge pack
• Laundry, flask, extra toilet roll, tissue paper
• Newspapers, rental of television, telephone charges, electricity and similar
facilities
Ineligible Expenses
Panel Hospitals – Klang Valley
Alpha Specialist Centre (Day Care)
Ara Damansara Medical Centre
Assunta Hospital Beacon Hospital BP Specialist Centre - Taman
Megah Columbia Asia Hospital - Bukit
Rimau Columbia Asia Hospital –
Klang Columbia Asia Hospital -
Petaling Jaya Columbia Asia Hospital -
Puchong DEMC Specialist Hospital Hospital Islam Az-Zahrah Hospital Pakar An-Nur Hospital Umra Kajang Plaza Medical Centre Kelana Jaya Medical Centre KPJ Ampang Puteri Specialist
Hospital KPJ Damansara Specialist
Hospital KPJ Kajang Specialist Hospital KPJ Klang Specialist Hospital KPJ Rawang Specialist Hospital KPJ Selangor Specialist
Hospital
KPMC Puchong Medical Centre
Manipal Hospitals Klang (Formely known as Arunamari Specialist Medical Centre)
Pantai Hospital Klang Pusat Pakar Mata Centre for
Sight (Day Care) Putra Medical Centre - Sungai
Buloh QHC Medical Centre Regen Specialist Centre (Day
Care) SALAM Shah Alam Specialist
Hospital Sentosa Specialist Hospital -
Klang Sri Kota Specialist Medical
Centre Subang Eye Specialist Centre
(Day Care) Subang Jaya Medical Centre
Sungai Long Medical Centre Sunway Medical Centre
The Tun Hussien Onn National Eye Hospital
Tropicana Medical Centre UITM Private Specialist Centre USJ Eye Specialist (Day Care)
Selangor
Cardiac Vascular SentralKuala Lumpur
Centre For G. I & Liver Disease (CENGILD)
Columbia Asia Hospital -Cheras
Columbia Asia Hospital -Setapak
Damai Service Hospital (HQ) - Jalan Ipoh
Gleneagles Kuala Lumpur Global Doctors Hospital Hospital Aman - Jalan
Ipoh Hospital Pakar Al-Islam Hospital Pusrawi iHeal Medical Centre
Institut Jantung Negara International Specialist
Eye Centre (Day Care) KL Eye Specialist Centre
(Day Care) Kuala Lumpur Sports
Medicine Centre KPJ Tawakkal Specialist
Hospital Life Care Diagnostic
Medical Centre
Lourdes Medical Centre Pantai Hospital Ampang Pantai Hospital Cheras Pantai Hospital Kuala
Lumpur Parkcity Medical Centre Prince Court Medical
Centre Quill Orthopaedic
Specialist Centre Sentosa Medical Centre -
Jalan Chemur Sentul Medical Centre Taman Desa Medical
Centre Tung Shin Hospital Rampai Puteri Medical
Centre UKM Specialist Centre
UM Specialist Centre
Kuala Lumpur
Panel Hospitals – Northern
Adventist Medical Centre (formerly known as Tanjung Medical Centre)
Bagan Specialist Centre Carl Corrynton Medical
Centre (formerly known as Tropicana Medical Centre)
Gleneagles Penang Hope Children Hospital ISEC Specialist Eye Centre
Penang (Day Care) Island Hospital
KPJ Penang Specialist Hospital
Lam Wah Ee Hospital Loh Guan Lye Specialists
Centre Mount Miriam Hospital Pantai Hospital Penang Penang Adventist Hospital
Penang
Anson Bay Medical Centre Apollo Medical Centre
Columbia Asia Hospital -Taiping
Hospital Fatimah KMC Medical Centre
(Formerly known as Kinta Medical Centre)
KPJ Ipoh Specialist Hospital
Pantai Hospital Ipoh Pantai Hospital Manjung
Perak Community Specialist Hospital
Sri Manjung Specialist Centre
Taiping Medical Centre
Perak
Amanjaya Specialist Centre Kedah Medical Centre
Metro Specialist Hospital Pantai Hospital Sungai Petani Putra Medical Centre - Alor Star
Kedah
Panel Hospitals – Southern
Columbia Asia Hospital - Iskandar Puteri (Formerly Knows as Columbia Asia Hospital - Nusajaya)
Gleneagles Medini Hospital Hospital Penawar Hospital Penawar Pandan City Kempas Medical Centre Kluang Utama Specialist Hospital KPJ Bandar Maharani Specialist Hospital KPJ Johor Specialist Hospital
Medical Specialist Centre - Wisma Maria Pantai Hospital Batu Pahat Pasir Gudang Specialist Hospital Puteri Specialist Hospital - Johor Bahru Putra Specialist Hospital - Batu Pahat Regency Specialist Hospital
Johor
Mahkota Medical CentreOriental Melaka Straits Medical Centre Pantai Hospital Ayer Keroh Putra Specialist Hospital - MelakaSouthern Specialist Eye Centre (Day Care)
Melaka
Columbia Asia Hospital - Seremban KPJ Seremban Specialist Hospital Mawar Medical Centre (Formerly
known as Mawar Renal Medical Centre)
Nilai Medical Centre (formerly known as NCI Hospital)
NSCMH Medical Centre (Negeri Sembilan Chinese Maternity Hospital and Medical Centre)
SALAM Senawang Specialist Hospital
Negeri Sembilan
Panel Hospitals – East Coast
Darul Makmur Medical Centre Hospital Pakar PRKMUIP IIUM Medical Specialist Centre KCDC Hospital KPJ Pahang Specialist Hospital
(Formerly Knows as KPJ KuantanSpecialist Hospital)
Kuantan Medical Centre
Pahang
Kuala Terengganu Specialist Hospital SALAM Specialist Hospital Kuala
Terengganu
Terengganu
Kota Bharu Medical Centre Perdana Specialist Hospital
Kelantan
Panel Hospitals – East Malaysia
Bintulu Medical Centre Borneo Medical Centre Columbia Asia Hospital - Bintulu Columbia Asia Hospital - Miri ISEC Specialist Eye Centre Sibu (Day Care) Kuching Specialist Hospital
Miri City Medical Centre Normah Medical Specialist Centre Rejang Medical Centre Sibu Specialist Medical Centre Timberland Medical Centre
Sarawak
Damai Specialist Hospital - Kota Kinabalu Gleneagles Kota Kinabalu Jesselton Medical Centre KPJ Sabah Specialist Hospital (formerly
known as Sabah Medical Centre)
Rafflesia Medical Centre Tawau Specialist Hospital
Sabah
Deposit
Some hospitals may require Personal Deposits (on top of treatment deposit granted by AXA) upon admission to pay excess or non-covered items under the policy. This deposit is refundable upon discharge.
This Deposit amount may vary, e.g. RM 300 / RM 500, depending on type of treatment.
27
Waiting Period30 days
Specified Illness - 120 days
Pre-Existing Conditions – 12 months
Schedule of Basic Medical Coverage
(Hospitalization & Surgical Benefit)
28
1. Any medical or physical conditions arising within the first thirty (30) days from the Insured Person’s coverage effective date or reinstatement date whichever is latest except for accidental injuries.
2. Specified IllnessNo benefits shall be payable for hospitalization, surgery and/or charges incurred which are caused directly or indirectly by Specified Illnesses and its related complications.
“Specified Illnesses” shall mean the following disabilities and its related complications, occurring within the first 120 days of insurance of the insured member:
(a)Hypertension, diabetes mellitus and Cardiovascular disease(b)All tumors, cancers, cysts, nodules, polys, stones of the urinary system and biliary
system(c) All ear, nose (including sinuses) and throat conditions(d)Hernias, hemorrhoids, fistulae, hydrocele, varicocele(e)Endometriosis including disease of the Reproduction system(f) Vertebro-spinal disorders (including disc) and knee conditions
Waiting Period –
Existing and New Employees & Dependents
Policy Exclusions
Plastic/Cosmetic surgery, circumcision, eye examination, glasses,acquisition of external prosthetic appliances or devices such as artificiallimbs, hearing aids, implanted pacemakers, lens (except for basic lens)and prescriptions thereof.
Dental conditions including dental treatment or oral surgery exceptas necessitated by Accidental Injuries to sound natural teeth occurringwholly during the Period of Insurance.
Private nursing, rest cures or sanitaria care, illegal drugs,intoxication, sterilization, venereal disease and its squeal, AIDS or ARC(AIDS Related Complex) and HIV related diseases and anycommunicable diseases required quarantine by law.
Policy Exclusions
Any treatment or surgical operation for congenital abnormalities or deformities including hereditary conditions.
Psychotic, mental or nervous disorders (including any neuroses and their physiological or psychosomatic manifestations).
Pregnancy, child birth (including surgical delivery), abortion and prenatal or postnatal care and surgical, mechanical or chemical contraceptive methods of birth control or treatment related to impotence or sterilization.
Hospitalisation primarily for investigatory purposes, diagnosis, X-ray examination, general physical or medical examinations, not incidental to treatment or diagnosis of a covered Disability or any treatment which is not Medically Necessary and any preventive treatments, preventive medicines or examinations carried out by a Physician and treatments specifically for weight reduction or gain.
Policy Exclusions
War or any act of war, declared or undeclared, criminal or terrorist activities, active duty in any armed forces, direct participation in strike, riots and civil commotion or insurrection.
Expenses incurred for donation of any body organ by an Insured Person and costs of acquisition of the organ including all costs incurred by the donor during organ transplant and its complications.
Private flying other than as a fare-paying passenger in any commercial scheduled airlines licensed to carry passengers over established routes.
Expenses incurred for sex changes.
Suicide, attempted suicide or intentionally self-inflicted injury while sane or insane.
Policy Exclusions
Investigation and treatment of sleep and snoring disorders, hormone replacement therapyand alternative therapy such as treatment, medical service or supplies, including but notlimited to chiropractic services, acupuncture, acupressure, reflexology, bone setting,herbalist treatment, massage or aroma therapy or other alternative treatment.
Costs/expenses of services of a non-medical nature such as television, telephones,telex services, radios or similar facilities and other ineligible non-medical items.
Policy Exclusions
Sickness or injury arising from illegal activities and playing professional sports or from
racing of any kind (except foot racing), hazardous sports such as but not limited to:
Base jumping, cliff diving, flying in an unlicensed aircraft or as a learner, martial arts,
free climbing, mountaineering with or without ropes, water skiing, scuba diving to a
depth of more than 10 metres, trekking to a height of over 2,500 metres, bungee
jumping, canyoning, hangliding, paragliding or microlighting, parachuting, potholing,
skiing off piste or any other winter sports activity carried out off piste.
Policy Exclusions
Cosmetic (aesthetic) surgery or treatment, or any treatment which relates to or is neededbecause of previous cosmetic treatment. However we will pay for reconstructive surgery if:
(a) It is carried out to restore function or appearance after an accident or following surgery for amedical condition, provided that member has been continuously covered under a plan ofours since the accident or surgery happened; and
(b) It is done at a medically appropriate stage after the accident or surgery; and
(c) We agree to the cost of the treatment in writing before it is done.
Note: This list is non-exhaustive. Please refer to the policy contract for the terms and conditions under this policy.
BEFORE AFTER
Claim ProcedureReimbursement Basis
Situations whereby you have to pay the hospital expenses first and file claim with us :
Admission to Non-Panel Hospitals
Hospitalisation outside Malaysia (overseas)
Emergency Accidental Outpatient Treatment
Accidental Dental Treatment
Emergency Sickness Treatment
Pre – Hospitalisation
Second Surgical Opinion
Outpatient Kidney Dialysis Treatment
Claim ProcedureReimbursement Basis
Complete the Claim Form:
• page 1 by claimant
• page 2 by doctor.
Submit ORIGINAL:
• hospital bills, itemised bills
• receipts
• test reports
Submit claim DOCUMENTS:
• within 30 days of completion of the event
Claim cheque will be ready within 14 working days upon submission of complete documentation.
(Claim forms can be obtained
from www.axa.com.my)
How to fill up the Claim Form
The insured to complete name, NRIC No, name of policyowner and
details such as date of birth, sex and contact no.
If you had an accident, please complete Part C. ACCIDENT
Please state date, time, place and how the accident happened.
How to fill up the Claim Form
If you fell sick, please complete Part D. SICKNESS
Please state nature of your illness, date first began and date first treated by a doctor.
Mandatory column on Part F. INSURED’S BANK DETAILS & Part G. AUTHORISATION TO
RELEASE INFORMATION. If the patient/covered person is a child, the insured/policyholder
should sign the statement of consent.
How to fill up the Claim Form
Email notification for successful e-banking