I. Product Overview
1. Insurance coverage: all the insured persons who participate in Shanghai basic medical insurance (definition 1).
2. Insurance age: unlimited.
3, health status: free of medical examination, past diseases can be insured and paid.
4. Waiting period: There is no waiting period.
5. Insurance period: one year.
6. Payment method: wholesale delivery
7. Insurance premium: 129 yuan/person/year.
8.2022 Safety Summary of Shanghai Bao Hui
9. Claims: If the insured person is hospitalized in the general department of the second-class or above designated medical insurance hospital in Shanghai or other places and holds the Shanghai medical insurance card for real-time settlement, he can apply for self-funded medical expenses claims for specific hospitalization; If you don't use Shanghai medical insurance card for real-time settlement, you must pass the settlement of Shanghai basic medical insurance before you can apply for medical expenses insurance claims for specific hospitalization. There is no need to use a medical insurance card for four responsibilities, such as domestic specific high-cost drug insurance premium/proton, heavy ion medical insurance premium/overseas special drug insurance premium /CAR-T therapeutic drug insurance premium, but you can apply for compensation only after seeing a doctor in the medical institution specified in the above four responsibilities in this product manual.
10. surrender: in June 1 you can surrender in full before the policy takes effect, and in July (inclusive) 1 you will not accept surrender after the policy takes effect.
Second, the insurance liability
(a) specific hospitalization medical expenses insurance
During the insurance period, the insured is hospitalized in the general inpatient department of a local designated hospital with secondary or above medical insurance due to illness or accidental injury (definition 2), and the reasonable and necessary out-of-pocket expenses incurred in specific hospitalization after deducting the annual deductible of Shanghai Basic Medical Insurance of 20,000 yuan (definition 3) are paid by non-previous patients and 50% by former patients (definition 4). Among them, the annual compensation limit for single product medicine fee (definition 5) is 300,000 yuan, the annual compensation limit for single hospitalization operation material fee is 200,000 yuan, and the annual compensation limit for PET-CT examination fee is 1 time.
The total amount of insurance money paid by an insurance company to the insured for specific hospitalization medical expenses is limited to 6,543,800 yuan. The insurance liability of the insurance company to the insured is terminated when the payment amount of insurance money for specific hospitalization medical expenses reaches 6.5438+0 million yuan at one time or cumulatively.
If the insured is hospitalized during the insurance period and does not leave the hospital after the expiration of the insurance period, the insurance company will still pay for the self-funded medical expenses incurred after the expiration of the insurance period according to the scope and proportion agreed in this contract until the end of this hospitalization, but the longest time is not more than 30 days.
(2) Insurance for certain high drug expenses in China.
During the insurance period, the insured is registered in the second-class and above hospitals in Shanghai, diagnosed as a specific disease by a designated specialist (definition 6), writes the outpatient medical records and makes prescriptions, and then buys and uses drugs that meet the requirements of diseases and indications in the Catalogue of Some High-priced Drugs in China (definition 8) in the outpatient departments of the second-class and above hospitals in Shanghai or pharmacies qualified to sell drugs in Shanghai. Drug expenses incurred by insurance companies are classified as follows:
The total insurance premium paid by the insurance company to the insured for some high domestic drug expenses is limited to 6,543,800 yuan. When the accumulated amount of insurance money paid by a high domestic drug fee reaches 6.5438+0 million yuan at one time or many times, the insurance company's liability to the insured is terminated.
If some drugs in the list of high-priced drugs in China are involved in charity relief, they shall be implemented according to the charity relief plan, and the expenses of drugs rescued by charitable organizations shall not be included in the payment scope of this product.
You can enjoy direct payment and door-to-door delivery service when you buy some high-priced drugs (definition 9) in special pharmacies.
(3) Proton and heavy ion medical insurance.
During the insurance period, if the insured receives proton and heavy ion therapy in a medical institution qualified for proton and heavy ion therapy in Shanghai (definition 10) for malignant tumor, the reasonable and necessary expenses incurred by the insurance company for positioning and making radiotherapy plan, as well as the expenses for implementing proton and heavy ion radiotherapy (excluding bed fees, chemotherapy fees, etc.) are 70% for non-previous patients and 30% for previous patients.
The total amount of proton and heavy ion medical insurance money paid by the insurance company to the insured is limited to 300,000 yuan. When the total amount of proton and heavy ion medical insurance paid at one time or multiple times reaches 300,000 yuan, the insurance company will terminate this responsibility to the insured.
(4) Overseas special drug expense insurance.
During the insurance period, the insured registered in Hainan Boao Super Hospital, Boao International Hospital, Boao Evergrande International Hospital and Hainan Hospital (Hainan Boao Research Hospital) affiliated to Shanghai Jiaotong University School of Medicine, and was diagnosed as a specific disease by a designated specialist, and after writing the outpatient medical record and prescribing, in the outpatient or inpatient departments of the above four hospitals, for those who meet the requirements of the Catalogue of Overseas Special Drugs (definition1/kloc-0
The total amount of insurance money paid by an insurance company for the overseas special drug expenses of the insured is limited to 300,000 yuan. When the amount of insurance money paid for overseas special drugs reaches 300,000 yuan at one time or many times, the insurance company's liability to the insured is terminated.
(5) Insurance premium for CAR-T therapeutic drugs.
During the insurance period, the insured meets the requirements of CAR-T treatment after being diagnosed by the designated specialist, carries out CAR-T treatment in the designated hospital for CAR-T treatment (definition 12), and purchases and uses the drugs listed in the Catalogue of Specific Drugs for CAR-T Treatment in the designated hospital for CAR-T treatment (definition 13). Insurance companies,
The total premium paid by the insurance company to the insured for CAR-T therapeutic drugs is limited to 500,000 yuan. When the accumulated insurance premium paid by CAR-T therapeutic drugs reaches 500,000 yuan at one time or many times, the insurance company's liability to the insured is terminated.
Third, the principle of compensation
The insurance company shall pay all liability insurance benefits within the scope of insurance liability under this contract. If the insured has obtained the corresponding expenses compensation by other means, the smaller of the compensation amount calculated by the insurance company according to the above insurance liability standard and the balance of medical or drug expenses after the insured has obtained compensation will pay the insurance money.
4. Exemption from liability
In the following cases, the insured's medical expenses occur, and this product is not responsible for paying insurance money:
1, infertility treatment, artificial insemination, pregnancy, delivery (including dystocia), abortion, birth control (including sterilization), prenatal and postpartum examination and complications caused by the above reasons.
2. Medical expenses for work-related injuries (occupational diseases).
3. Medical expenses that should be borne by the third party.
4. Medical expenses for going abroad (including Hong Kong, Macao and Taiwan).
5, laws, regulations, policies and documents shall not be paid, the insurer shall not be liable for the payment of insurance benefits.
6. The insurance company will not be responsible for all medical expenses incurred since the insured was hospitalized or discharged from the hospital ("hanging bed hospitalization" means that the insured who has gone through formal hospitalization procedures is not in bed or in the hospital for 24 hours, including the case that there is no treatment for several consecutive days during hospitalization, and only nursing expenses, medical expenses and bed fees occur.
7. Experiments or research treatments without scientific or medical approval and their consequences; Treatment without the approval of the local authority, or drugs or drugs without the approval or approval of the local government; All kinds of medical identification, including but not limited to medical accident identification, psychiatric identification, pregnant women's fetal sex identification, injury identification, paternity identification, genetic identification fees;
8. Plastic surgery, cosmetic surgery, transsexual surgery, complications of the aforementioned surgery or medical accidents caused by the aforementioned surgery; Medical expenses incurred by the insured in prevention, fitness, rest or recuperation, medical consultation, health care or non-disease treatment; Glasses or contact lenses, vision orthoses, boosters, orthotics, hearing AIDS, artificial limbs, artificial eyes, wheelchairs, crutches and other functional auxiliary materials or rehabilitation devices.
9. Exemption of domestic specific high drug expenses and overseas special drug expenses.
(1) The drug prescription is inconsistent with the scope of the Catalogue of Specific High-priced Drugs in China or the Catalogue of Special Drugs Abroad.
(2) Drugs purchased by hospitals or pharmacies other than those agreed in this product.
(3) the cost of each drug prescription for more than one month.
(4) Some prescriptions of high-priced drugs in China are inconsistent with the indications, usage and dosage listed in the drug instructions approved by China Food and Drug Administration; Relevant medical data cannot prove that the insured's disease meets the indications for using specific drugs.
(5) The prescription of overseas special drugs is inconsistent with the indications, usage and dosage listed in the drug instructions approved by the administrative department of the drug export place; Relevant medical data cannot prove that the insured's disease meets the indications for using specific drugs.
(6) Drug prescriptions are not issued by designated specialists registered in the outpatient department of designated hospitals.
(7) The disease status of the insured is confirmed as drug resistance through examination, and the expenses incurred (drug resistance refers to a. The disease progress of the solid tumor focus is defined as drug resistance according to RECIST (evaluation standard of curative effect of solid tumor). B. Non-solid tumors (including malignant tumors such as leukemia, multiple myeloma, myelofibrosis and lymphoma). ) usually there is no definite mass or it is very small and difficult to find. After standardized treatment, according to the guidelines of relevant professional institutions (including: China Society of Clinical Oncology (CSCO), Hematology Branch of Chinese Medical Association, Hematology Professional Committee of China Anti-Cancer Association, National Comprehensive Cancer Network (NCCN) of National Health and Health Commission and the United States, etc.),
(8) Medical expenses incurred by the insured who meets the application conditions for charitable relief drugs, and fails to submit relevant applications or the submitted application materials are incomplete, resulting in the failure of the application for relief projects; The insured passes the aid audit, but fails to receive the aid drugs due to the insured's reasons, which shall be deemed as the insured's voluntary waiver of the applicable insurance rights and interests under this contract.
Verb (abbreviation of verb) explanation
1, Shanghai basic medical insurance: refers to Shanghai employees' basic medical insurance and Shanghai urban and rural residents' basic medical insurance.
2. Hospitalization: refers to the insured's admission to the formal ward of the hospital for treatment and formal admission and discharge procedures, but does not include the following situations:
(1) The insured is admitted to the emergency observation room, family sickbed and joint ward;
(2) The insured is admitted to a rehabilitation ward (rehabilitation department) or receives rehabilitation treatment;
(3) During hospitalization, the insured did not receive examination and treatment related to admission diagnosis within 65,438+0 days, or stayed in hospital for less than 24 hours within 65,438+0 days, unless he went to other hospitals for temporary treatment according to the doctor's advice;
(4) Other unreasonable hospitalization, including not being treated for several days in a row during hospitalization, only charging nursing fees and bed fees.
3. Self-funded medical expenses for specific hospitalization: refers to the specific drug expenses, surgical materials expenses and examination expenses among the self-funded medical expenses in the bills settled by Shanghai basic medical insurance during hospitalization, excluding the medical expenses of individuals and classified self-funded parts of basic medical insurance.
Specific drug expenses: refers to the drug expenses paid by the basic medical insurance fund during hospitalization with the drug approval number or the Registration Certificate of Imported Drugs and Pharmaceutical Products issued by the national drug supervision and administration department, including the expenses of western medicines, Chinese patent medicines and Chinese herbal pieces, but excluding the following situations: (1) Chinese herbal pieces mainly playing a nourishing role; (2) Animals and animal organs that can be used as medicine; (3) drugs with beauty and weight loss as health care functions.
4. Previously sick people: refers to those who have registered in Shanghai workers' outpatient service or urban and rural residents' medical insurance within two years before the date of enrollment, or have enjoyed the treatment of serious illness, and the scope is as follows:
(1) severe uremia dialysis (hemodialysis, peritoneal dialysis);
(2) Anti-rejection after renal transplantation;
(3) Malignant tumor treatment (chemotherapy, endocrine specific therapy, radiotherapy, isotope therapy, interventional therapy, traditional Chinese medicine treatment);
(4) Treating some mental diseases (schizophrenia, moderate and severe depression, mania, obsessive-compulsive disorder, mental retardation with mental disorder, epilepsy with mental disorder, paranoid psychosis);
(5) Students in colleges and universities in Shanghai suffer from hemophilia and aplastic anemia.
5. Drug cost per unit product: refers to the total cost of drugs with the same chemical name.
6. Designated specialties: Designated specialties shall meet the following four qualifications at the same time: (1) having valid China people's * * * and China doctor qualification certificates; (2) Have a valid practicing certificate of People's Republic of China (PRC) doctors and register with relevant departments on schedule; (3) A valid certificate of the title of physician with the title of attending physician or above in People's Republic of China (PRC); (4) When doctors diagnose or prescribe patients, the hospitals they serve are secondary hospitals and above, and they serve clinical departments related to prescription indications.
7. Specific diseases: refers to lung cancer, head and neck cancer, gastric cancer, melanoma, esophageal cancer, liver cancer, breast cancer, prostate cancer, ovarian cancer, lymphoma, brain tumor, leukemia, multiple myeloma, neuroblastoma, colorectal cancer, fallopian tube cancer, peritoneal cancer, gastrointestinal stromal tumor, cholangiocarcinoma, urothelial cancer, Fabry's disease, mucopolysaccharide storage disease (type II)
8, domestic specific high drug list
* Insurance companies will adjust the list of specific high-priced drugs in China in a timely manner according to the update of the national list of essential drugs.
9. Special pharmacy:
10. Medical institutions with proton and heavy ion therapy qualifications in Shanghai: refer to hospitals that are approved by the health administrative department of Shanghai to engage in proton and heavy ion therapy medical practice.
1 1, list of overseas special drugs
12, CAR-T treatment designated hospital
The medical institutions in Shanghai that have received training and certification in the use of Agilent Injection of Fosun Kaite Biotechnology Co., Ltd./Ruijile Injection of Shanghai Yaoming Junuo Biotechnology Co., Ltd. are as follows:
13, CAR-T list of specific drugs for treatment