Cigna SME Series

The product information in this webpage does not represent the full terms of the Policy and the full terms can be found in the Policy document.

The Policy is issued for a term of one year and shall be automatically renewed at the end of each Policy Year provided that the premium due on the following Policy Anniversary is fully paid and received by the Company before the expiration of the grace period.

The initial premium shall be calculated at the Premium Rate(s) specified in the Schedule of Rates, and each subsequent premium shall be calculated at the Premium Rate(s) on the Premium Due Date.

Premium adjustments involving the return of unearned premiums shall be limited to the period of twelve (12) months prior to the evidence for such adjustments being received. The Company reserves the right to adjust the premium rates of this Policy on any Premium Due Date. Factors leading to premium rates adjustment may include (but are not limited to) our overall experience in claims and expenses incurred by and / or in relation to this product, change of eligibility of a class of individuals for insurance, and change in the material factors bearing on the risk assumed. The Company may adjust any premium rate by giving advance notice in writing to you. Except for factors including the change of eligibility of a class of individuals for insurance and change in the material factors bearing on the risk assumed, any other increase in premium rate should become effective at least twelve (12) months after effective date of the Policy / any previous increase in premium rates.

Except for the initial premium payment, there will be a grace period of thirty-one (31) days following each Premium Due Date. This Policy will remain effective during the grace period. If any premium for the Person Insured in any class is not paid before the expiration of the grace period, this Policy will automatically discontinue for all Persons Insured in such class at the expiration of the grace period with the loss of insurance coverage.

If any relevant facts related to the Person Insured have been found material and incorrectly reported to the Policyholder or to the Company, the validity of the insurance policy and the premium payable shall be determined based on the true facts.

Termination of member coverage

An Individual’s insurance under this Policy shall terminate on the earliest of the following dates:

1. the date when an Individual dies or ceases to be a member of a class of Individuals eligible for insurance;
2. the date of discontinuance of this Policy;
3. the end of the Policy Year during which the Individual attains the Age of sixty-nine (69) years;
4. the date of termination of employment as hereafter defined;
5. (For Cigna CareChoice Group Plan only) the end of the Policy Year during which the Policyholder has notified the Company in writing an Individual ceases to be employed in Hong Kong or based in Hong Kong for one hundred and eighty five (185) days or more during that Policy Year.

Cessation of Active Work shall be deemed termination of employment, except that while an Individual is absent from work on account of Sickness or Bodily Injury, employment shall be deemed to continue until premium payments for such Individual’s insurance are discontinued. At the option of the Policyholder, the insurance of an Individual may be continued during an authorized leave of absence granted by the Policyholder for reasons other than Sickness or Bodily Injury but not beyond twenty-four (24) calendar months from the date the leave of absence commences.

Termination of Policy

1. The Company reserves the right to discontinue this Policy on any Premium Due Date,
   (a) for all classes of individuals, when there are less than 3 individuals are insured under the Policy; or
   (b) for any class of individuals, when there are less than 100% of individuals in such class are insured under the Policy; provided the Company gives the Policyholder at least thirty-one (31) days’ notice of its intent to discontinue.
2. This Policy may be terminated as at any Premium Due Date by either the Policyholder or the Company by mailing written notice of termination to the other party, not less than thirty-one (31) days before the Premium Due Date on which such termination shall be effective. Termination shall be without prejudice to any claim originating prior to the effective date of termination.

Due to inflation, the future cost of living may be higher than today and the current benefits may not be sufficient to meet future insurance needs.

If you have an existing medical insurance policy and intend to switch the coverage to this plan, please be aware of the potential implications in terms of insurability, claims eligibility and financial values regarding the change to the insurance arrangement. Some benefits under the existing policy may be changed or not be covered under this plan due to changes in policy features, Age, health conditions, occupation, lifestyle, habit or recreational activities. Also, riders or supplementary benefits under your existing insurance policy may not be available under this plan.

Benefits under the existing insurance policy will no longer be payable to you if you surrender the Policy or allow it to lapse. Besides, you may need to start a new waiting period (if any) in respect of certain benefits under the terms and conditions of the new policy.

To make a claim, please login to our customer portal or register at http://www.mycigna.com.hk or download our MyCigna app. For details of procedures by claims type, please visit the Company website https://www.cigna.com.hk/en/customer-service/insurance-claim-procedure

We only cover medical expenses relating to Medically Necessary treatment subject to Reasonable and Customary charges.

“Medically Necessary” means the necessity to have a medical service which is:

1. consistent with the diagnosis and customary medical treatment for the condition at a Reasonable and Customary charge;
2. in accordance with standards of good and prudent medical practice;
3. necessary for such a diagnosis or treatment;
4. not furnished primarily for the convenience of the Person Insured, Physician, Chinese Medicine Practitioner, Physiotherapist, Anaesthetist or any other medical service providers;
5. furnished at the most appropriate level which can be safely and effectively provided to the Person Insured; and
6. with respect to hospital confinement, not furnished primarily for diagnostic scanning purpose, imaging examination or physical therapy.

“Reasonable and Customary” in relation to a fee, a charge or an expense, means any fee or expense which

1. is charged for treatment, supplies (inclusive of medication) or medical services that are Medically Necessary and in accordance with standards of good medical practice for the care of an injured or ill person under the care, supervision or order of a Physician;
2. does not exceed the usual level of charges for similar treatment, supplies (inclusive of medication) or medical services in the locality where the expense is incurred; and
3. does not include charges that would not have been made if no insurance existed.

The Company reserves the right to determine whether any particular Hospital/medical charge is a Reasonable and Customary charge with reference to (but not limited) any relevant publication or information made available, such as schedule of fees, by the government, relevant authorities and recognized medical association in the locality. The Company reserves the right to adjust any and all benefits payable in relation to any Hospital/medical charges which are not Reasonable and Customary.

The following list is for reference only and it is not a full list of exclusions. Please refer to the Policy provisions for the complete list and details of exclusions.

Cigna shall not be liable to pay any claim or expenses incurred directly or indirectly resulting from or consequent upon or contributed by the following:

1. Any sickness or bodily injury for which the Person Insured has received medical treatment, diagnosis, or prescribed drugs during the ninety (90) days preceding the effective date of his coverage (i.e. pre-existing conditions) unless the Person Insured affected by these conditions has been insured under this Policy continuously for twelve (12) months.
2. Bodily injuries arising directly or indirectly from riots or war, declared or undeclared.
3. Routine physical examinations, or health check-ups or test not incident to treatment or diagnosis of an actual sickness or bodily injury. This is not applicable to the Network Annual Health Checkup of Cigna CareChoice Group Plan.
4. (a) eye refractions, fitting of glasses, contact lenses;
   (b) hearing aids; and
   (c) gingivitis, any dental or oral care, treatment or surgery of any nature whatsoever except procedure necessitated by damage to sound natural teeth as a result of an accidental injury occurring during the period of insurance.
5. Bodily injuries due to insanity, self-infliction or participation in illegal acts or terrorism; conditions related to functional disorders of the mind or psychiatric disease; rest cure or sanitaria care (e.g. neurasthenia, anxiety state, anaemia); treatment of an optional nature (e.g. anorexia, acne); drug addiction or alcoholism.
6. Congenital conditions.
7. (a) treatment occasioned by or resulting from pregnancy, childbirth, miscarriage or abortion.
   (b) treatment relating to birth control, infertility or sterilization of either sex.
8. Any venereal disease or AIDS disease.
9. Any bodily injury or sickness for which compensation is payable under any laws or regulations or any other health insurance policy or scheme except to the extent that such charges are not reimbursed by such laws or regulations or other policy or scheme.
10. Not Medically Necessary.

Notes: “Cigna”, “the Company”, “We”, “our” or “us” herein refers to Cigna Worldwide General Insurance Company Limited.