Cigna HealthFirst Elite 360 Medical Plan

Terms & Conditions

IMPORTANT INFORMATION

Mis-statement of non-health related information

If any non-health related information (E.g. age, sex or smoking Habit) of the Insured Person has been mis-stated in the Application or in any subsequent information or document submitted to Cigna Healthcare for the purpose of the application, Cigna Healthcare may adjust the premium payable on the basis of the correct information or declare the Policy void as from the Policy Effective Date if the application of the Insured Person should have been rejected based on the correct information.

Misrepresentation or fraud

If any material fact relating to the health related information of the insured person has been incorrectly stated in, or omitted from the Application or any statement or declaration made for or by the Insured Person in the Application or in any subsequent information or document submitted to Cigna Healthcare for the purpose of the application; or any Application or claim submitted is fraudulent or where a fraudulent representation is made, Cigna Healthcare may declare the Policy Void as from the Policy Effective Date.

Premium

1. Premium Level
The premium corresponding to the Accommodation Room Type, Area of Cover and Deductible you select is determined based on the age, sex and smoking habit of the Insured Person at Policy commencement and at the time of Renewal upon each anniversary date of the Policy.

2. Non-payment of premium
If you fail to pay the initial premium in full for the Policy on or before the Policy Issuance Date or the Policy Effective Date (whichever is the earlier), the Policy shall be deemed to be void as from the Policy Effective Date for all purposes. Accordingly, Cigna Healthcare shall not be liable to pay any benefit under the Policy.
Except for the initial premium payment, a Grace Period after any Premium Due Date will be allowed for payment of premium or any part thereof. The coverage of the Policy will remain in force during the Grace Period, but Cigna Healthcare shall have the right to deduct at its discretion any due premium payment from the benefit payable under the Policy if there is any benefit payable during the Grace Period.
If any premium remains unpaid at the end of the Grace Period, the Policy shall terminate on the Premium Due Date on which the unpaid premium was first due.

3. Premium Adjustment
Cigna Healthcare reserves the right to revise the premium of the Policy upon each Renewal at its sole discretion by taking into account such factors as Cigna Healthcare determines to be relevant for the purpose of revising the premium, including but not limited to the overall experience in claims and expenses incurred by and / or in relation to this product.

Benefits

1. Benefit in General

   For Medical Services rendered in Hospitals in the mainland China that is neither a Tier 3 Class A or above nor a Designated Mainland China Hospital, no benefits under the Policy shall be payable by Cigna Healthcare.

   Except for the Accidental Death Benefit payment, Cigna Healthcare shall pay any benefit payable under this Policy to the Policy Holder or if the Policy Holder is not living at the time of payment, to the Policy Holder’s estate.

   For the Accidental Death Benefit payment, Cigna Healthcare shall pay it to the Beneficiary, and if no Beneficiary is designated or the Beneficiary is not living at the time of the payment, to the Policy Holder.



2. Choice of ward class

   If the Insured Person is Confined in Hong Kong or Macau in a room type of a level higher than the Accommodation Room Type, the Eligible Expenses payable and other payable expenses under the Basic Policy shall be subject to the adjustment factor applicable as follows:

   Accommodation Room Type	Room type Confined	Adjustment factor
   Semi-Private Room	Standard Private Room	50%

   No benefits under the Basic Policy shall be payable for Confinement in class of suite/ VIP/ deluxe room of a Hospital



3. Territorial scope of cover

   Country of residence refers to the country where the Insured Person has stayed in for 185 days or more during the period of 365 consecutive days before the expenses incurred date.
   Except Emergency Treatment, the benefits under the Basic Policy and the Optional Insurance Benefits (if applicable) shall be payable only if the Medical Services are provided in the Area of Cover. For Emergency Treatment, the coverage under the Policy is worldwide.
   If the Insured Person’s Country of Residence is the US on the Eligible Expenses Incurred Date or on the day when other payable expenses are incurred, all benefits payable under the Policy shall be reduced to sixty percent (60%) of the Eligible Expenses and other payable expenses incurred in the US. Notwithstanding the foregoing, and for the avoidance of doubt, the benefit limits as specified in the Benefit Schedule and the Deductible shall remain unchanged.



4. Calculation of benefit payable

   Benefit Payable

   {Amount of Eligible Expenses or other payable expenses LESS ( - ) (the Eligible Expenses or other payable expenses incurred for the same Disability reimbursed by another party or by us under another insurance plan, or the Deductible under the Policy, whichever is the highest)} TIMES ( x ) adjustment factor for territorial scope of cover (if applicable) TIMES ( x ) adjustment factor for choice of ward class (if applicable)

Other Insurance Coverage

If you have taken out other insurance coverage besides the Policy, you shall have the right to claim under any such other insurance coverage or the Policy. However, if you or the Insured Person has already recovered all or part of the expenses from any such other insurance coverage, Cigna Healthcare shall only be liable for such amount of Eligible Expenses and other payable expenses, if any, which is not compensated by any such other insurance coverage.

Conversion of Policy

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.

Renewal

The Basic Policy and the Optional Insurance Benefits (if applicable) under the Policy shall be effective for an initial period of 12 Calendar Months and thereafter guaranteed to be automatically Renewable, for successive periods of 12 Calendar Months each, provided that payment of premium is paid on or before each Anniversary Date and that Cigna Healthcare continue to issue new policy(ies) under the Basic Policy and the Optional Insurance Benefits (if applicable) of “Cigna HealthFirst Elite 360 Medical Plan”.
Cigna Healthcare reserves the right to revise the terms and conditions, the Standard Premium and/or the Benefit Schedule of the Policy upon each Renewal.

Termination

1. The Policy shall terminate upon the occurrence of the earliest of the following events:
   • the death of the Insured Person;
   • the cancellation or non-renewal of the Policy by the Policy Holder;
   • the cancellation of the Policy by Cigna Healthcare due to mis-statement of non-health information, misrepresentation or fraud, non-payment of initial payment, duplicate policies or when Shortfall is not settled within 14 days after a Shortfall advice is issued by Cigna Healthcare to the Policy Holder;
   • non-payment premium by the end of the Grace Period; or
   • when the lifetime benefit limit is reached.
2. The Optional Pharmacy Benefit shall automatically terminate upon the first Anniversary Date immediately after the lifetime limit).

Inflation Risk

Your current planned benefit may not be sufficient to meet your future needs since the future cost of living may become higher than they are today due to inflation. Where the actual rate of inflation is higher than expected, you may receive less in real terms even if Cigna Healthcare meet all of our contractual obligations.

Medically Necessary

"Medically Necessary" shall mean the need to have medical service for the purpose of investigating or treating the relevant Disability in accordance with the generally accepted standards of medical practice and such medical service must:

• require the expertise of, or be referred by, a Registered Medical Practitioner;
• be consistent with the diagnosis and necessary for the investigation and treatment of the Disability;
• be rendered in accordance with standards of good and prudent medical practice, and not be rendered primarily for the convenience or the comfort of the Insured Person, his family, caretaker or the attending Registered Medical Practitioner;
• be rendered in the setting that is most appropriate in the circumstances and in accordance with the generally accepted standards of medical practice for the Medical Services; and
• be furnished at the most appropriate level which can be safely and effectively provided to the Insured Person.

Reasonable and Customary

"Reasonable and Customary" shall mean, in relation to a charge for Medical Service, such level which does not exceed the general range of charges being charged by the relevant service providers in the locality where the charge is incurred for similar treatment, services or supplies to individuals with similar conditions, e.g. of the same sex and similar Age, for a similar Disability, as reasonably determined by Cigna Healthcare. The Reasonable and Customary charges shall not in any event exceed the actual charges incurred.
In determining whether a charge is Reasonable and Customary, Cigna Healthcare shall make reference to the followings (if applicable):

• treatment or service fee statistics and surveys in the insurance or medical industry;
• internal or industry claim statistics;
• gazette published by the government; and/or
• other pertinent source of reference in the locality where the treatments, services or supplies are provided.

Key exclusions

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

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

The following items are applicable to all benefits:

(a) Expenses incurred for Medical Services provided as a result of Pre-existing Conditions and any special exclusion(s) set out under the Policy, except for Disability which has been fully disclosed in the Application and Cigna Healthcare agrees not to classify as an exclusion under the Policy.

(b) Expenses incurred for treatments, procedures, medications, tests or services which are not Medically Necessary.

(c) Expenses incurred for the whole or part of the Confinement solely for the purpose of diagnostic procedures or allied health services, including but not limited to physiotherapy, occupational therapy and speech therapy, unless such procedure or service is recommended by a Registered Medical Practitioner for Medically Necessary investigation or treatment of a Disability which cannot be effectively performed in a setting for providing Medical Services to a Day Patient.

(d) Expenses incurred for treatment for Human Immunodeficiency Virus (“HIV”) and its related Disability, except such occurrences are covered under HIV/ AIDS treatment, “HIV Infection due to Blood Transfusion” under Optional Pharmacy Benefit (if applicable), or “Occupationally acquired HIV” under Optional Pharmacy Benefit (if applicable).

(e) Expenses incurred for Medical Services as a result of Disability arising from or consequential upon the dependence, overdose or influence of drugs, alcohol, narcotics or similar drugs or agents, self-inflicted injuries or attempted suicide, illegal activity, or venereal and sexually transmitted Disease or its sequelae (except for HIV and its related Disability, where the above (d) exclusion applies).

(f) Expenses incurred for – services for

1. beautification or cosmetic purposes, except for breast reconstruction surgery covered by breast reconstructive surgery benefit; or
2. correcting visual acuity or refractive errors that can be corrected by fitting of spectacles or contact lenses, including but not limited to eye refractive therapy, LASIK and any related tests, procedures and services.

(g) Expenses incurred for prophylactic treatment or preventive care, including but not limited to general check-ups, routine tests or screening procedures for asymptomatic conditions, screening or surveillance procedures based on the health history of the Insured Person and/or his family members, Hair Mineral Analysis (HMA), immunization or health supplements.

(h) Expenses incurred for dental treatment and oral and maxillofacial procedures performed by a Registered Dentist except for Emergency Treatment and surgery during Confinement arising from an Accident or to the extent covered by the Accidental Emergency dental treatment. Follow-up dental treatment or oral surgery after discharge from Confinement shall not be covered. For the avoidance of doubt, this exclusion shall not apply to Optional Dental Benefits (if applicable).

(i) Expenses incurred for Medical Services and counselling services relating to maternity conditions and its complications, including but not limited to diagnostic tests for pregnancy or resulting childbirth, abortion or miscarriage; birth control or reversal of birth control; sterilization or sex reassignment of either sex; infertility including in-vitro fertilization or any other artificial method of inducing pregnancy; or sexual dysfunction including but not limited to impotence, erectile dysfunction or pre-mature ejaculation, regardless of cause, except such occurrences of maternity conditions and its complications are covered under pregnancy complications.

(j) Expenses incurred for the purchase of durable medical equipment or appliances including but not limited to wheelchairs, beds and furniture, airway pressure machines and masks, portable oxygen and oxygen therapy devices, dialysis machines, exercise equipment, spectacles, hearing aids, special braces, walking aids, over-the-counter drugs, air purifiers or conditioners and heat appliances for home use, except such expenses are covered by home facility enhancement benefit for Stroke. For the avoidance of doubt, this exclusion shall not apply to rental of medical equipment or appliances during Confinement or on the day of the Day Case Procedure.

(k) Expenses incurred for traditional Chinese medicine treatment, including but not limited to herbal treatment, bone-setting, acupuncture, acupressure and tui na, and other forms of alternative treatment including but not limited to hypnotism, qigong, massage therapy, aromatherapy, naturopathy, hydropathy, homeotherapy and other similar treatments, except to the extent covered by the traditional Chinese medicine treatment and three Critical Illnesses auxiliary benefit. For the avoidance of doubt, this exclusion shall not apply to Optional Outpatient Benefits (if applicable).

(l) Expenses incurred for experimental or unproven medical technology or procedure in accordance with the common standard, or not approved by the recognised authority, in the locality where the treatment, procedure, test or service is received.

(m) Expenses incurred for Medical Services provided as a result of birth defect(s), Congenital Condition(s), Hereditary Condition(s), or any related Disability, except such occurrences of birth defect(s), Congenital Condition(s), Hereditary Condition(s), or any related Disability are covered under “Medullary Cystic Disease” under Optional Pharmacy Benefit (if applicable).

(n) Expenses which have been reimbursed under any law, or medical program or insurance policy provided by any government, company or other third party.

(o) Expenses incurred for treatment for Disability arising from War, civil war, invasion, acts of foreign enemies, hostilities, rebellion, revolution, insurrection, military or usurped power, or Terrorism.

(p) Expenses incurred for treatment for developmental conditions including but not limited to learning difficulties such as dyslexia, behavioral problems such as autism or attention deficit disorder (ADHD); or physical development problems such as short height.

(q) Expenses incurred for treatment for obesity, or which is necessary because of obesity, which includes but not limited to slimming class, aids and drugs. Cigna Healthcare shall only pay for gastric banding or gastric bypass surgery if the Insured Person has a body mass index (BMI) of fourty (40) or over and had been diagnosed as being morbidly obese; and can provide documented evidence of other methods of weight loss which have been tried over the past twenty-four (24) Calendar Months.

(r) Expenses incurred for artificial life maintenance including mechanical ventilation where such treatment will not or is not expected to result in the Insured Person’s recovery, or restore the Insured Person to his/her previous state of health, except such expenses are covered under “Vegetative State” under Optional Pharmacy Benefit (if applicable).

(s) Expenses incurred for fetal surgery or treatment.

(t) Expenses incurred for treatment for a related condition resulting from addictive conditions and disorders, including but not limited to smoking cessation.

(u) Expenses arising from sleeping disorders except for –

1. sleep test (subject to a limit of one (1) sleep test per Policy Year) if there is a diagnosis of sleep apnea of the Insured Person; and
2. treatment in relation to sleep apnea and as recommended in writing by a Specialist.

(v) Expenses incurred for or in connection with speech therapy that is not restorative in nature; or if such therapy is used to improve speech skills that have not fully developed, can be considered custodial or educational or intended to maintain speech communication.

(w) Expenses incurred for sex change operations or any treatment needed to prepare for or recover from these operations including complication arising out of such treatment.

(x) Expenses incurred for gene therapy and cell therapy.

(y) Expenses incurred for non-medical services, including but not limited to guest meals, radio, telephone, photocopy, taxes (apart from VAT and GST charged on Eligible Expenses), medical report charges, fax and the like.

(z) Expenses incurred for mental, psychiatric or nervous illness, personality disorder and character disorders, except such occurrences are covered under psychiatric treatments, post-Confinement/ Day Case Procedure auxiliary treatment, psychiatric outpatient treatment or psychological outpatient treatment, or “Alzheimer’s Disease/Dementia“ under Optional Pharmacy Benefit (if applicable).

(aa) Expenses incurred for organ transplantation, except such occurrences are covered under organ transplantation benefit or “Major Organ Transplantation” under Optional Pharmacy Benefit (if applicable).

(bb) Expenses arising from the Insured Person’s engagement and participation in:

1. naval, military or air force service or operations, armed force or service with the police of any nation;
2. professional sports or hazardous activities such as but not limited to rock climbing or mountaineering, parachuting, hang-gliding (whether powered or not), para-gliding, bungee-jumping or any kind of race other than by foot;
3. cave, wreck or free diving, professional diving, diving without holding the correct diving certification such as a Professional Association of Diving Instructors (PADI) and diving at depths more than forty (40) meters;
4. professional, semiprofessional or competitive winter sports, cross country skiing or snowboarding, ski or snowboard jumping, heli-skiing, off-piste skiing or snowboarding, speed skiing;
5. working at height (over twenty (20) feet);
6. operating heavy machinery;
7. aviation or aerial activities, except air travel as a fare-paying passenger in or as a member of the aircrew of a properly licensed, fixed-wing multi-engined aircraft constructed to carry passengers and operated by a licensed commercial air carrier, or in a helicopter owned and operated by a commercial concern which is licensed for the regular transportation of fare-paying passengers provided such helicopter is operating only between commercial airports and/or licensed commercial heliports, and provided further that in either event such travel is not for the purpose of any trade or technical operation in or on the aircraft; or
8. manufacture, storage, filling, breakdown, handling and transport of any explosive (including but not limited to firework or firecracker) or chemical material.

(cc) In respect of any Optional Dental Benefits (if applicable), in addition to the above (a) to (bb) exclusions, Cigna Healthcare shall not pay expenses incurred for the following:

1. Appliances or restoration necessary to increase vertical dimension or restore an occlusion;
2. Dental implants or transplants;
3. Cosmetic dentistry procedures such as bleaching and veneers;
4. Orthodontic services;
5. Repair or replacement of orthodontic appliances;
6. Placement of bone grafts or extra-oral substances in the treatment of periodontal disorders;
7. Procedures or appliances to correct congenital malformations;
8. Treatment of malignancies, cysts, or neoplasms;
9. Replacement of lost or stolen dentures;
10. Services or treatment for, or associated with, temporomandibular joint (TMJ) dysfunction or disorder, or for orthognathic surgery;
11. Services or supplies intended to diagnose or treat any condition that is occupational Injury or Disease; or
12. Replacement or additions to existing dentures or bridgework.

(dd) In respect of the Optional Pharmacy Benefit (if applicable), in addition to the above (a) to (bb) exclusions, Cigna Healthcare shall not pay expenses incurred for the following:

1. Any drugs that are experimental or investigational; or
2. Replacement of claimed Western Medications due to loss, theft, damaged, spoiled or expired.

In addition to the above (a) to (dd) exclusions, Cigna Healthcare shall not pay any Accidental Death Benefit in relation to or arising from the following:

(ee) Illness, Disease, bacterial or viral infection, even if contracted by an Accident. This does not exclude bacterial infection that is the direct result of an Accidental cut or wound or Accidental food poisoning.

(ff) Medical or surgical treatment, except where such treatment is rendered necessary by Injury within the scope of the Accidental Death Benefit.

(gg) Pregnancy, childbirth, miscarriage, abortion or complications arising from any of them even though such loss may have been accelerated or induced by Injury.

(hh) Any illegal act of the Insured Person in the country or territory where Injury occurs.

(ii) Being in a state of insanity or psychiatric or psychological disturbance.

(jj) Being under the influence of alcohol or drugs unless the drugs are properly prescribed by a Registered Medical Practitioner and were not taken for the treatment of drug addiction.

(kk) Driving any kind of vehicle while the alcohol level in the Insured Person’s breath, blood or urine is higher than the legal limit in the country or territory where Injury occurs.

(ll) Service in any armed force while: i) in the time of War; ii) under orders for warlike operations; or iii) restoration of public order. For the avoidance of doubt, armed force shall include any police force of a country or territory.

(mm) War or any act of War, invasion, act of foreign enemy, hostilities (whether War be declared or not), strike, riot and/or Civil Commotion, civil war, rebellion, revolution, insurrection, military or usurped power, or Terrorism.

(nn) Taking part in any air sport, air travel or any other kind of aviation activities, other than travelling as a fare-paying passenger on regular scheduled commercial aircraft which is provided and operated by an airline or air charter company which is properly licensed to do so.

(oo) Suicide, attempted suicide, suicide pact or deliberate self-inflicted Injury, while sane or insane.

(pp) Workers involved in the manufacture, storage, filling, breakdown, handling and transport of any explosive (including but not limited to firework or firecracker).

(qq) The Insured Person participating in or conducting training for any of the following activities:

1. underwater swimming or diving and use any type of equipment to aid breathing;
2. any kind of climbing, or mountaineering using rope or guides;
3. pot-holing;
4. parachuting, any kind of gliding, ballooning, bungee-jumping or micro-lighting;
5. cave, wreck or free diving, professional diving, diving without holding the correct diving certification such as a Professional Association of Diving Instructors (PADI) and diving at depths more than forty (40) meters;
6. professional, semiprofessional or competitive winter sports, cross country skiing or snowboarding, ski or snowboard jumping, heli-skiing, off-piste skiing or snowboarding, speed skiing;
7. hunting;
8. driving or riding in any kind of race; or
9. professional sports.

The above insurance plan is underwritten by Cigna Worldwide General Insurance Company Limited.

The above information is for reference only and does not constitute any contract or any part thereof between Cigna Healthcare and any other parties. Please read the product brochure for details. For details of full terms, conditions and exclusions, please refer to the policy provisions. Cigna Healthcare will be happy to provide a specimen of policy upon your request.