Dokumen Polisi Kemasukan Hospital dan Pembedahan Pekerja Asing

Whereas the Policy Holder / Insured Person by an application and declaration which shall be the basis of this contract and is deemed to be incorporated herein has applied to PACIFIC & ORIENT INSURANCE CO. BERHAD (hereinafter call “the Company”) for the insurance contained in this policy and has paid the premium stated in the Policy Schedule as consideration for such insurance for the period stated therein.

Now this Policy Withesseth that if during the Period of Insurance, any sickness, disease, illness or accidental injury necessitates the Insured Person to be confined to a Malaysian Government Hospital for treatment, the Company will subject to the terms, provisos, exclusions and conditions of and endorsed on this Policy, pay to the Insured / Insured Person or his legal personal representatives the sum or sums stated in the Schedule of Benefits.

Provided always that this policy shall become effective as of the date stated in the Policy Schedule. This Policy shall be issued for one year and at the end of each period of insurance may be renewed for another year subject to the consent of the Company.

This Policy is issued in consideration of the payment of premium as specified in the Policy Schedule and pursuant to the answers given in Your Proposal Form (or when you applied for this insurance) and any other disclosures made by you between the time of submission of your Proposal Form (or when you applied for this insurance) and the time this contract is entered into. The answers and any other disclosures given by you shall form part of this contract of insurance between you and us. However, in the event of any pre-contractual misrepresentation made in relation to your answers or in any disclosures given by you, only the remedies in Schedule 9 of the Financial Services Act 2013 will apply.

This Policy reflects the terms and conditions of the contract of insurance as agreed between you and us.

This Policy is issued in consideration of the payment of premium as specified in the Policy Schedule and pursuant to the answers given in your Proposal Form (or when you applied for this insurance) and any other disclosures made by you between the time of submission of your Proposal Form (or when you applied for this insurance) and the time this contract is entered into. The answers and any other disclosures given by you shall form part of this contract of insurance between you and us. In the event of any pre-contractual misrepresentation made in relation to your answers or in any disclosures made by you, it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance.

This Policy reflects the terms and conditions of the contract of insurance as agreed between you and us.

ACCIDENT shall mean a sudden, unintentional, unexpected, unusual, and specific event that occurs at an identifiable time and place which shall, independently of any other cause, be the sole cause of bodily injury.

ANY ONE DISABILITY shall mean all of the periods of disability arising from the same cause including any and all complications there from except that if the Insured Person completely recovers and remain free from further treatment (including drugs, medicines, special diet or injection or advice from the conditions) of the disability for at least ninety (90) days following the latest date of discharge and subsequent disability from the same cause shall be considered as though it were a new disability.

DISABILITY shall mean a Sickness, Disease, Illness or the entire Injuries arising out of a single or continuous series of causes.

CONGENITAL CONDITIONS shall mean any medical or physical abnormalities existing at the time of birth, as well as neo-natal physical abnormalities developing within 6 months from the time of birth. They will include hernias of all types and epilepsy except when caused by a trauma, which occurred after the date that the Insured Person was continuosly covered under this Policy.

DAY shall mean the definition of a charging day adopted by the Malaysian Government Hospital concerned.

DAY SURGERY shall mean a patient who needs the use of a recovery facility for a surgical procedure on a pre-planned basis at the hospital / specialist clinic (but not for overnight stay).

DOCTOR or PHYSICIAN or SURGEON shall mean a registered medical practitioner qualified and licensed to practice western medicine and who, in rendering such treatment, is practing within the scope of his licensing and training in the geographical area of practice, but excluding a doctor, physician or surgeon who is the Insured Person himself.

HOSPITAL CONFINEMENT shall mean the Insured Person being duly registered and admitted as an in-patient in a Malaysian Government Hospital for more than twelve (12) hours.

HOSPITAL shall mean an establishment duly constituted and registered as a hospital for the care and treatment of sick and injured persons as paying bed-patients, and which:-

1. has organized facilities for diagnosis treatment and major surgery,
2. provides 24 hours a day nursing services by registered graduate nurses,
3. Is under the supervision of a Physician, and
4. Is not primarily a clinic; a place for custodial care for alcoholics or drug addicts; a nursing, rest or convalescent home for the aged and similar establishment

MALAYSIAN GOVERNMENT HOSPITAL shall mean a hospital which charges of services are subject to the Fees Act 1951 Fees (Medical) Order 1982 and/or its subsequent amendments if any.

SICKNESS, DISEASE OR ILLNESS shall mean a physical condition marked by a pathological deviation from the normal healthy state.

INJURY shall mean bodily injury caused solely by Accident.

POLICYHOLDER shall mean a person or corporate entity who has applied for this insurance from the Company and who is an employer or bona fide foreign workers.

INSURED PERSON shall mean the Eligible Person having accepted by the Company to participate in the scheme described in the Policy Schedule.

ELIGIBLE PERSON shall mean the present and future full-time foreign worker employees of the Policyholders who are between eighteen (18) to sixty (60) years of age and who are bona fide holders of valid work permits/Pas Lawatan Kerja Sementara issued by the relevant Malaysian government authority.

INTENSIVE CARE UNIT shall mean a section within the Malaysian Government Hospital which is designated as an Intensive Care Unit by the Malaysian  Government Hospital and which is maintained on a twenty-four (24) hour basis solely for treatment of patients in critical condition and is equipped to provide special nursing and medical services not available elsewhere in the Malaysian Government Hospital.

OVERALL ANNUAL LIMIT shall mean benefits payable in respect of expenses incurred for treatment provided to the Insured Person during the period of insurance shall be limited to Overall Annual Limits as stated in the Schedule of Benefits irrespective of type/types of disability. In the event the Overall Annual Limit having been paid, all insurance for the Insured Person hereunder shall immediately cease to be payable for the remaining policy year.

PRE-EXISTING ILLNESS shall be limited to disabilities which existed before the effective date of cover and for which the Insured Person should have reasonably been aware of. An Insured Person may be considered to have reasonable knowledge of a pre-existing condition where the condition is one for which:-

(a) the Insured Person had received or is receiving treatment;

(b) medical advice, diagnosis, care or treatment has been recommended;

(c) clear and distinct symptoms are or were evident; or

(d) its existence would have been apparent to a reasonable person in the circumstances.

REASONABLE AND CUSTOMARY CHARGES shall mean charges for medical care which is medically necessary shall be considered reasonable and customary to the extent that it does not exceed the general level of charges being made by others of similar standing in the locality where the charged is incurred, when furnishing like or comparable treatment, services or supplies to individual of the same sex and of comparable age for a similar sickness, disease or injury and in accordance with accepted medical standards and practice could not have been omitted without adversely affecting the Insured Person’s medical condition.

SPECIFIED ILLNESS shall mean the following disabilities and its related complications, occurring within the first 120 days of Insurance of the Insured Person:

(a) Cardiovascular disease

(b) All cancers

SURGERY shall mean any of the following medical procedures:

(a) To incise, excise or electrocauterize any organ or body part, except for dental services.

(b) To repair, revise, or reconstruct any organ or body part.

(c) To reduce by manipulation a fracture or dislocation.

(d) Use of endoscopy to remove a stone or object from the larynx, bronchus, trachea, esophagus, stomach, intestine, urinary bladder, or urethra

POLICY shall mean this agreement together with any endorsements therein, signed by the company, the policy Schedule attached hereto and the application form of the Insured Person all of which shall constitute the entire contract between the parties.

PERIOD OF INSURANCE shall mean the period specified in the Policy Schedule and during which the Insured Person is in immediate employment of the Insured or until the cessation of the work/employment permit whichever is the earlier BUT EXCLUDING the period when the Insured Persons returns to his/her home country. Cover ceases from the time he/she leaves Malaysia and resumes upon his/her return to Malaysia. The territorial limit of this Policy is within Malaysia only.

DAILY HOSPITAL ROOM AND BOARD (MAXIMUM UP TO THIRTY (30) DAYS)

Reimbursement of the Reasonable and Customary Charges Medically Necessary for room accommodation and meals. The amount of the benefits shall be equal to the actual charges made by Malaysian Government Hospital during the Insured Person’s confinement, but in no event shall the benefit exceed, for any one day, the rate of Room and Board Benefits, and the maximum number of days as set forth in the Schedule of Benefits. The Insured Person will only be entitled to this benefit while confined to a Hospital as an in-patient.

INTENSIVE CARE UNIT (MAXIMUM UP TO FIFTEEN (15) DAYS)

Reimbursement of the Reasonable and Customary Charges Medically Necessary for actual room and board incurred during confinement as an in-patient in the Intensive Care Unit of the Malaysian Government Hospital. This benefit shall be payable equal to the actual charges made by the Malaysian Government Hospital subject to the maximum benefit for any one day, and maximum number of days, as set forth in the Schedule of Benefits. Where the period of confinement in an Intensive Care Unit exceeds the maximum set forth in the Schedule of Benefits, reimbursement will be restricted to the standard Daily Hospital Room and Board rate. No Hospital Room and Board Benefits shall be paid for the same confinement period where the Daily Intensive Care Unit Benefits is payable.

HOSPITAL SUPPLIES & SERVICES

Reimbursement of the Reasonable and Customary Charges actually incurred for Medically Necessary general nursing, prescribed and consumed drugs and medicines, dressings , splints, plaster casts, x-ray, laboratory examinations, electrocardiograms, physiotherapy, basal metabolism test, intravenous injections and solutions, administration of blood and blood plasma but excluding the cost of blood and plasma whilst the Insured Person is confined as an in-patient in a Malaysian Government Hospital, up to the amount stated in the Schedule of Benefits.

OPERATING THEATRE

Reimbursement of the Reasonable and Customary Operating Room charges incidental to the surgical procedure not exceeding the limits as set forth in the Schedule of Benefits.

SURGICAL FEES

Reimbursement of the Reasonable and Customary Charges for a Medically Necessary surgery by the Specialists during confinement in hospital. If more than one surgery is performed for Any One Disability, the total payments for all the surgeries performed shall not exceed the maximum stated in the Schedule of Benefits.

ANAESTHETIST’S FEE

Reimbursement of the Reasonable and Customary Charges by the Anaesthetist for the Medically Necessary administration of anaesthesia not exceeding the limits as set forth in the Schedule of Benefits.

IN-HOSPITAL PHYSICIAN VISIT (MAXIMUM UP TO THIRTY (30) DAYS)

Reimbursement of the Reasonable and Customary Charges by a Physician for Medically Necessary visiting an in-paying patient while confined for a non-surgical disability subject to a maximum of one (1) visit per day not exceeding the maximum number of days and amount as set forth in the Schedule of Benefits.

IN-HOSPITAL SPECIALIST CONSULTANT VISIT (MAXIMUM UP TO THIRTY (30) DAYS)

Reimbursement of the Reasonable and Customary Charges for the consultation by a legally licensed and qualified Medical Specialist, which is recommended by a Physician because of illness or injury while confined in hospital. The total amount payable shall not exceed the maximum specified in the Schedule of Benefits for Any One Disablity.

AMBULANCE FEES/MEDICAL REPORT FEES

Reimbursement of the Reasonable and Customary Charges incurred for necessary domestic ambulance service (inclusive of attendant) to and/or from the Malaysian Government Hospital. Payment will not be made if the Insured Person is not Hospitalised and subject to the limits set forth in the Schedule of Benefits. Under this benefit, the Company shall also reimburse the Insured the cost of obtaining medical report(s) but only if such reports are specifically required by the Company for its processing of claims.

PERSONS ELIGIBLE

Eligible Persons for insurance under this Policy are those present and future full-time foreign worker employees of Policyholder who are actively engaged at their usual work on the date the persons are eligible to join the Policy.

Present foreign worker employees will be eligible to participate in the insurance on the commencement date of the Policy. Future foreign worker employees will be eligible to participate in the insurance according to the date mentioned in the application form.

If a foreign worker employee is not actively engaged at his/her usual work on the date he/she would otherwise be eligible in accordance with the above mentioned requirement, his/her eligibility date will be deferred to the first (1st) day of the month immediately following his/her return to active full-time work.

PERIOD OF COVER AND RENEWAL

This Policy shall become effective as for the date stated in the Schedule. The Policy Anniversary shall be one year after the effective date and annually thereafter. On each such anniversary, this Policy is renewable at the premium rates in effect at that time as notified by the Company.

GEOGRAPHICAL TERRITORY

All benefits provided in this policy are applicable within Malaysia only for twenty-four (24) hours a day.

LIMITATION OF BENEFITS

All benefits provided in this Policy are only payable in the event the Insured Person is confined in a non-corporatised Malaysian Government Hospital.

This contract does not cover any hospitalization, surgery or charges caused directly or indirectly, wholly or partly, by any one (1) of the following occurrences:

1. Pre-existing illness. However, this exclusion is waived in the event the Insured Person passes the medical examination as confirmed by Fomema Sdn Bhd (FOMEMA) within 30 days from the Insured Person’s arrival to Malaysia.

2. Specified lllnesses occurring during the first one hundred and twenty (120) days of continuous cover

3. Plastic/Cosmetic surgery, circumcision, eye examination, glasses and refraction or surgical correction of nearsightedness ( Radial keratotomy ) and the use or acquisition of external prosthetic appliances or devices such as artificial limbs, hearing aids, implanted pacemakers and prescriptions thereof.

4. Dental conditions including dental treatment or oral surgery except as necessitated by Accidental Injuries to sound natural teeth occurring wholly during the Period of Insurance.

5. Private nursing, rest cures or sanitaria care, illegal drugs, intoxication, sterilization, venereal disease and its sequelae, AIDS

(Acquired Immunodeficiency Syndrome) or ARC (AIDS Related Complex) and HIV (Human Immunodeficiency Virus) related diseases, and any communicable diseases requiring quarantine by law.

6. Any treatment or surgical operation for congenital abnormalities or deformities including hereditary conditions

7. Pregnancy, child birth (including surgical delivery), miscarriage, abortion and prenatal or postnatal care and surgical, mechanical or chemical contraceptive methods of birth control or treatment pertaining to infertility. Erectile dysfunction and tests or treatment related to impotence or sterilization.

8. Hospitalization 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.

9. Suicide, attempted suicide or intentionally self-inflicted injury while sane or insane.

10. War or any act of war, declared or undeclared, criminal or terrorist activities, active duty in any armed forces, direct participation in strikes, riots and civil commotion or insurrection.

11. Ionising radiation or contamination by radioactivity from any nuclear fuel or nuclear waste from process of nuclear fission or from any nuclear weapons material.

12. 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.

13.  Investigation and treatment  of sleep and snoring disorders, hormone replacement therapy and alternative therapy such as treatment, medical service or  supplies, including but not limited to chiropractic services, acupuncture, acupressure, reflexology, bonesetting, herbalist treatment, massage or aromatherapy or other alternative treatment.

14. Care or treatment for which payment is not required or to the extent which is payable by any other insurance or indemnity covering the Insured person and Disabilities arising out of duties of employment or profession that is covered under a Workman’s Compensation Insurance Contract.

15. Psychotic, mental or nervous disorders, (including any neuroses and their physiological or psychosomatic manifestations).

16. Costs / expenses of services of a non-medical nature, such as television, telephones, telex services, radios or similar facilities, admission kit / pack and other ineligible non-medical items

17. Sickness or Injury arising from racing of any kind (except foot racing), hazardous sports such as but not limited to skydiving, water skiing, underwater activities requiring breathing apparatus, winter sports, professional sport and illegal activities.

18. Private flying other than as a fare-paying passenger in any commercial scheduled airlines licensed to carry passengers over established routes.

19. Expenses incurred for sex changes.

This Policy and the Schedules shall be read together as one contract and any words or expression to which a specific meaning has been attached in any part of this Policy or of the Policy Schedules shall bear such specific meaning wherever it may appear.

NOTICE

Every notice or communication to the Company shall be in writing and sent to the Company. No alterations in the terms of this Policy or any endorsement thereon, will be held valid unless the same is signed or initialled by an authorized representative of the Company.

CONDITION PRECEDENT TO LIABILITY

The due observance and the fulfillment of the terms, provisions and conditions of this Policy by the Insured and the Insured Person and in so far as they relate to anything to be done or complied with by the Insured and Insured Person shall be conditions precedent to any liability of the Company.

MISREPRESENTATION / FRAUD

If the proposal or declaration of the Insured is untrue in any respect or if any material fact affecting the risk be incorrectly stated herein or omitted therefrom, or if this insurance, or any renewal thereof shall have been obtained through any misstatement, misrepresentation or suppression, or if any claim made shall be fraudulent or exaggerated, or if any false declaration or statement shall be made in support thereof, then in any of these cases, this Policy shall be void.

PREMIUM

During the Period of Insurance, the premium for insurance under this Policy is not guaranteed. The Company shall have the right to change the rate at which premiums shall be calculated, at the start of any Policy Year, provided that the Company notifies the Insured Persons at least ninety (90) days in advance of the date such premium is due.

CLAIM PROCEDURES

1. The Insured Person shall within 30 days of a Disability that incurs claimable expenses, give written notice to the Company stating full particulars of such event, including all original bills and receipts, and a full Physician’s report stipulating the diagnosis of the condition treated and the date the Disability commenced in the Physician’s opinion and the Physician’s summary of the cost of treatment including medicines and services rendered. Failure to furnish such notice within the time allowed shall not invalid any claim if it is shown not to have been reasonably possible to furnish such notice and that such notice was furnished as soon as was reasonably possible.
2. The Insured Person shall immediately procure and act on proper medical advice and the Company shall not be held liable in the event a treatment or service becomes necessary due to failure of the Insured Person to do so.
3. Upon completion of submission of all relevant documents, the reimbursement of the claims shall be made within thirty (30) working days by the Company.

CANCELLATION

This Policy may be cancelled by the Policyholder at any time by giving a written notice to the Company; and provided that no claims have been made during the current policy year, the Policyholder shall be entitled to a refund of the premium as follows:-

 
GOVERNING LAW

This Policy is issued under the laws of Malaysia and is subject and governed by the laws prevailing in Malaysia.

LEGAL PROCEEDINGS

No action at law or in equity shall be brought to recover on this Policy prior to expiration of sixty (60) days after written proof of loss has been furnished in accordance with the requirements of this Policy. If the Insured Person shall fail to supply the requisite proof of loss as stipulated by the terms, provisions and conditions of the Policy, the Insured Person may, within a grace period of one calender year from the time that the written proof of loss was to be furnished, submit the relevant proof of loss to the Company with cogent reason(s) for the failure to comply with the Policy terms, provisions and conditions. The acceptance of such proof of loss shal be at the sole and entire discretion of the Company. After such grace period has expired, the Company will not accept, for any reason whatsoever, such written proof of loss.

TERMINATION OF INDIVIDUAL INSURANCE

The insurance of any one Insured Person shall terminate on the earlier happening of the following events:-

1. Upon expiration of the Insured Person’s work permit or upon the termination of the employment contract between the Policyholder and the Insured Person named in the Schedule, or
2. From the date of the Immigration Department’s Letter of Discharge, or
3. On the death of the Insured Person, or exhaustion of the Overall Annual Limit for that particular Insured Person, or
4. On the Policy Anniversary immediately following the 60th birthday of the Insured person, or
5. On the date when premium payments for the Insured Person’s insurance are discontinued due to any cause, or
6. On the date of termination of the Policy by either the Policyholder or the Company or
7. At the mid-night standard Malaysian time on the last day of the Period of Insurance unless the Insured Person is confined to a Government Hospital at such time. If this being the case, the time of termination shall be extended to:-
1. the time the Insured Person is discharged from Government Hospital, or
2. the time the Overall Annual Limit shall have been exhausted whichever is the first to occur

ALTERATIONS

The Company reserves the right to amend the terms and provisions of this Policy by giving a 30 days prior notice in writing by ordinary post to the insured’s last known address in the Company’s records, and such amendment will be applicable from the next renewal of this Policy. No alteration to this Policy shall be valid unless Authorised by the Company and such approval is endorsed thereon. The insurer should give 30 days prior written notice to the insured according to the last recorded address for any alterations made.

GRACE PERIOD

Notwithstanding the Cash before Cover condition, a Grace period of fourteen (14) days from its due date will be allowed for payment of each premium after the first Policy Year. During such fourteen (14) days, the Company shall remain liable thereunder if by the last of such days, the premium is actually paid.

If any premium is not paid in respect of this Policy Contract before the end of the Grace period, this Policy Contract shall be deemed as terminated at the expiry date of the policy.

The Policyholder shall read this Policy carefully and if any error or misdescription be found herein, or if the cover were not in accordance with the wishes of the Policyholder, advise should at once be given to the Company and the Policy returned for attention.

Disputes can be referred to: Ombudsman for Financial Services (OFS) (Formerly known as Financial Mediation Bureau) Tel No : 03-2272 2811

The Policyholder shall read this Policy carefully and if any error or misdescription be found herein, or if the cover were not in accordance with the wishes of the Policyholder, advise should at once be given to the Company and the Policy returned for attention.

Disputes can be referred to: Ombudsman for Financial Services (OFS) (Formerly known as Financial Mediation Bureau) Tel No : 03-2272 281