top-upmedicalinsuranceplan附加醫療保險計劃课件

The University of Hong Kong 香港大學 Top-Up Medical Insurance Plan 附加醫療保險計劃,The primary purpose of the Top Up Medical Insurance Plan is to cover eligible medical expenses that exceed HKUs Staff Medical Benefits Scheme (SMBS). 本附加醫療福利計劃之主要目的是涵蓋大學根據僱員醫療福利計劃（SMBS）所提供的醫療福利與實際住院費的差額之保障。,The Plan is a self-paid insurance plan. 自行供款保險計劃 。 Effective on 1st September, 2005 本計劃的保障生效日為二五年九月一日 。 Anniversary date is 1st September each year. 週年日為每年九月一日。,Eligibility 參加資格,All HKU appointees (including fractional appointees) who are eligible for first class or second class hospitalisation care under the SMBS and who are under the age of 65. 凡大學僱員（包括比率式聘任的僱員）享有頭等或二等住院福利而年齡在六十五歲以下，均可以同等條款參加本計劃。 No medical examination is required to join the Plan. 參加本計劃毋需驗身 。,Dependants Coverage 家屬保障,When you apply to join the Plan, you must also enrol your eligible dependants. 閣下申請參加本計劃時，必須與合資格家屬一起參加。 Dependants include your spouse and unmarried child(ren) who are wholly or partly maintained by you. 合資格家屬指閣下之配偶及需閣下供養之未婚子女 。,An eligible dependant need not be enrolled immediately if he/she is: 在下列情況下，合資格家屬毋須參加本計劃： Residing overseas; 居住海外 Receiving full-time education overseas; 在海外接受全日制教育 Covered under another group medical protection/insurance scheme provided by the spouses employer (this does not include any individually purchased medical insurance plan) 享有配偶僱主提供之團體醫療保障保險計劃 (並不包括個人購買之醫療保障計劃)。,HKU SMBS大學僱員醫療福利計劃 ANNUAL LIMIT PER MEMBER 每人每年申領上限 HK$400,000,ANNUAL EXCESS of TOP UP PLAN 附加醫療保險計劃每年自付額 HK$10,000 (Plan 1 計劃一 ) OR HK$5,000 (Plan 2 計劃二 ),TOP UP INSURANCE ANNUAL COVER 附加醫療保險計劃每保障年度最高賠償額 HK$750,000,TOP UP COVER 附加保障,Treatments at HA Hospitals 入住醫管局轄下的醫院 The Plan covers hospitalisation and treatment of injuries and illnesses, approved by the Director of UHS, in public hospitals under the Hospital Authority (HA) 本計劃保障凡經UHS主任批准因受傷、發病引致入住醫管局轄下的醫院或私家醫院之住院及醫療費用,The Plan covers the shortfall between the benefits entitlement under the SMBS and the medical charges as gazetted in the HAs List of Charges effective from April 1, 2003. 當入住醫管局轄下醫院，本計劃的保障為大學SMBS所提供的醫療福利與政府刊登於憲報並於二零零三年四月一日起生效的公立醫院收費之差額。,TOP UP COVER 附加保障,Treatments at Private Hospitals 入住私家醫院 The Plan covers the shortfall between the benefits entitlement under the SMBS and the medical expenses incurred, up to the limits as set out in the Benefits Schedule for Confinement in Private Hospitals under the Plan in Appendix III.,本計劃的保障為大學SMBS所提供的醫療福利與入住私家醫院實際住院費之差額。最高賠償額已詳列於附件III - 入住私家醫院保障表內,Hospital Accommodation 住院保障,Hospitalisation coverage will be in accordance with the SMBS. 本計劃之住院保障是根據大學SMBS所訂明 Plan 1 for appointees who are eligible for 1st class hospitalisation benefit. 計劃一 ：適用於可享用頭等病房福利的僱員 Plan 2 for appointees who are eligible for 2nd class hospitalisation benefit. 計劃二 ：適用於可享用二等病房福利的僱員,Up to 50% of the following privately purchased medical items approved by the Director of UHS:- a) Expensive and special outpatient expenses, that is, chemotherapy drugs, catheters and PET scans b) Percutaneous Transluminal Coronary Angioplasty (PTCA) and other consumables for interventional cardiology c) Cardiac pacemaker d) Intraocular lens 下列自購醫療項目的百份之五十費用： 甲）昂貴及特殊門診費用，如化療藥物、導管及正電子發射斷層照相術 （PET SCAN ) 乙）經皮徹照心臟血管成形術（PTCA）及介入性心臟科的消耗品； 丙）心臟調節器（起搏器） 丁）眼內鏡 （人造晶體）,Plan 1 計劃一 Appointees who are eligible for 1st class hospitalisation benefit. The annual excess amount is: HK$10,000 每年自付額為港幣一萬元 Eligible for Plan 1 under Benefits Schedule for Confinement in Private Hospitals in Appendix III. 入住私家醫院保障-附件III 計劃一,Plan 2 計劃二 Appointees who are eligible for 2nd class hospitalisation benefit The annual excess amount is: HK$5,000 每年自付額為港幣伍仟元 Eligible for Plan 2 under Benefits Schedule for Confinement in Private Hospitals Appendix III. 入住私家醫院保障-附件III 計劃二,Points To Note The excess will not be pro-rata even though the membership is for a partial year. 即使受保人在年中參加本計劃，每年自付額不會有相應調整。 All medical treatment and hospitalisation must be referred and approved by the Director of UHS before payment under this Plan can be made. 任何醫療及住院費用必須先得到UHS主任轉介及批准，承保公司方會接受索償。,Cover extends to: 保障範圍 i) pre-existing medical conditions (已存在的疾病) ii) mental illnesses and psychiatric disorders, subject to a benefit sub-limit of HK$15,000 per Policy Year per insured member (精神或心理病，每一受保人每年的最高限額為港幣一萬五仟元 ). iii)the cost of an accompanying bed when a child member under the age of 12 is hospitalised (陪同十二歲以下小童住院的加床費).,The overall maximum benefits limit is HK$750,000 per Policy Year per insured member. Where the insured member joins the Plan during the second half of the Policy Year, the overall limit will be reduced by 50% for the initial Policy Year. 每一受保人於每保障年度的最高賠償額為港幣七十五萬元，若受保人於保障年的下半年度投保，首年保額會調低至百份之五十,Case I,Mr A, eligible for 2nd class benefit under SMBS Had cancer and required chemotheraphy Total cost incurred: $45,000 for the treatment SMBS reimbursed 50%, i.e., $22,500 Balance claimed on Top-up Plan: $22,500 Top-up Plan reimbursed amount: $22,500 - $5,000 (annual excess) = $17,500,甲君享有大學僱員醫療計劃二等住院福利 染上癌病並需接受化療 化療費用： 四萬五千元 大學僱員醫療計劃賠償一半金額， 即二萬二千五百元 向附加保險計劃索償餘額： 二萬二千五百元 減 五千元 (每年自付額) = 一萬七千五百元,Case II,Mr B, eligible for 1st class benefit under SMBS Had heart operation and stayed in HA hospital for 11 days. Incurred cost was $223,000 SMBS paid $120,000, while Mr B bear the daily maintenance charge of $248 x 11 = $2,728 Balance claimed Top-up plan : $103,000 Top-up Plan Paid: $103,000 - $10,000 (annual excess) = $93,000,乙君享有大學僱員醫療計劃頭等住院福利 因心臟手術入住公立醫院十一天。費用為二十二萬三千元 大學僱員醫療計劃賠償十二萬元，但乙君須自行負擔每日住院費二百四十八元 ，十一天總額為二千七百二十八元 餘額十萬三千元可向附加保險計劃索償 附加保險計劃賠償金額：十萬三千元 減 一萬元 (每年自付額) = 九萬三千元,Case III,Mr C, eligible for 2nd class benefit under SMBS Had cancer and had multiple admissions to private hospital for 28 days Total incurred cost was $350,000. SMBS paid $200,000 while Mr C bears the daily maintenance charge of ($184 x 28 days) = $5,152 Balance for Top-up Plan: $150,000 BasicTop-up Plan Paid: $100,000 - $5,000 (annual excess) = $95,000 Shortfall is: $150,000 - $100,000 = $50,000 SMMB Paid: $50,000 - $1,000 (SMMB deductible) x 80%=$39,200,丙君享有大學僱員醫療計劃二等住院福利 因癌病需入住私家醫院二十八天 費用總額為三十五萬元。大學僱員醫療計劃賠償二十萬元，但丙君須自行負擔每日住院費一百八十四元，二十八天總額為五千一百五十二元 十五萬餘額可向附加保險計劃索償 基本計劃賠償金額為十萬元， 另減五千元自付金額，餘額為九萬五千元 賠償差額為五萬元正 額外醫療保障賠償：五萬元減一千元(額外醫療保障自付金額) ，餘數八折賠償，應得金額為三萬九千二百元,The claim form together with the relevant supporting documents must be submitted to the UHS, within 60 days starting from the first date of treatment, or in the case of hospitalisation, within 60 days after discharge from the hospital. Late submission will result in the Insurer rejecting your claims. 閣下須於求診或出院日後六十天內遞交索償表，並附上有關証明文件致UHS， 逾期申請將不予受理。,Claims procedures 索償程序 The Insurer will process the staff members