Applicable object
Employees who participate in the SIBCO Comprehensive Benefit Coverage as a group and choose medical coverage, and the participating organization has paid for it.
coverage
1. Outpatient, emergency and hospitalization expenses incurred by the applicable object within the provisions;
2. Suitable for ----- full-time healthy employees under the age of 60 who do not suffer from any of the following diseases
For: Malignant tumors, heart disease (heart dysfunction grade II or above), myocardial infarction, leukemia, hypertension (grade II or above), cirrhosis of the liver, chronic obstructive bronchial disease, cerebrovascular disease, chronic kidney disease, diabetes mellitus, aplastic anemia, congenital disease, mental illness, epilepsy, specific infectious diseases, AIDS, venereal diseases, intervertebral disc herniation or being hospitalized for illness, and Take full or half vacation
Scope of medical treatment
In mainland China.
Visit a designated hospital
Municipal, district and county level (including) public hospitals within the scope of medical insurance (but not including the foreign guest ward, special diagnosis ward, special need ward and high-level ward and other similar wards or wards of these hospitals). Emergency or rescue can go to any public hospital designated by the medical insurance for treatment, but the local secondary (including) medical insurance designated public hospital for treatment.
Note: The following hospitals are not designated hospitals
Shanghai Navy 411 Hospital
Shanghai Pudong Yangsi Hospital
Shanghai Hongkou District Quyang Hospital
Shanghai Hongkou District maternal and Child Health Hospital
Shanghai Pudong Anda Hospital
Shanghai Hongkang Hospital
Beijing Military Region General Hospital
Beijing 309 PLA Hospital (now the Second Affiliated Hospital of PLA General Hospital)
Beijing Armed Police Corps Hospital
Armed Police Beijing Corps second hospital
Beijing Private Hospital Chinese Medicine Hall (i.e. Hong Medicine Hall)
Yangqiao Hospital, Beijing Hospital of Traditional Chinese Medicine
Beijing Air Force Hospital
Beijing Naval General Hospital
Tianjin PLA 464 Hospital
Tianjin People's Liberation Army 254 Hospital
Payment standard for outpatient, emergency and inpatient medical expenses
1. Outpatient and emergency medical expenses: Within the effective period of the protection liability, the outpatient and emergency medical expenses incurred by the applicable subjects due to diseases shall be paid 100% by the individual's own part within the scope of Shanghai Medical insurance.
2. Hospitalization: Within the validity period of the insurance liability, the applicable object of participating in Shanghai medical insurance and the cardholder for medical treatment will be granted 100% of the self-financed portion within the scope of Shanghai Municipal Medical insurance; The applicable subjects who do not participate in Shanghai medical insurance shall pay the standard starting payment amount within the scope of Shanghai medical insurance and 15% above the starting payment standard for their own part according to the scope of Shanghai medical insurance;
*** In each insurance year, the total payment of outpatient, emergency and inpatient medical expenses is capped at 50,000 yuan;
17 diseases are excluded from the outpatient, emergency and inpatient medical expenses.
3. Maternity medical expenses for female employees:
1) For the medical expenses incurred by the female insured under the conditions of national family planning laws and regulations and within the scope of insurance, the Company shall compensate the expenses at 100% ratio. For those who do not participate in Shanghai Medical insurance, 15% of the cost of childbirth hospitalization in line with family planning shall be paid in accordance with the provisions of Shanghai medical insurance.
2) Within each insurance year, the following expenses for each female insured shall not exceed RMB 5000 yuan.
- Fees for prenatal examinations for pregnant women;
- the cost of delivery (excluding the cost of the baby);
- Medical expenses incurred by married persons for abortion (within the scope of family planning) or for terminating pregnancy;
- The cost of getting the ring, taking the ring, penetrating the ring and ligation of the married person;
- Expenses for abortion protection and safety;
-- Maternity bed fee: The compensation limit is RMB100 per person per day.
3) Explanation of maternity costs:
The Company shall, upon receipt of such medical expense claim application, immediately pay the medical insurance money according to the agreed time if the information is complete and there is no doubt about it; Claims for medical expenses incurred by a married person as a result of abortions or operations to terminate a pregnancy after each occurrence; The maternity expenses shall be uniformly claimed from the Company after delivery;
-- The cost of childbirth (excluding the cost of the baby) shall be paid by the Company according to the insurance liability, and the maternity medical expenses subsidy of RMB 3,000 provided by Shanghai Social insurance shall not be deducted;
- If the period during which the pregnancy and perinatal examination fee is incurred by the female insured spans two insurance years, the Company shall compensate the accumulated maternity expenses of the female insured according to the welfare standard of the insurance year in which the child is delivered.
Instructions for filing a claim
1. Claim application procedures:
1) When Chinese employees apply for claims, they can send complete materials required for claims to the customer service Department of our company.
2) The required materials are:
◇ Fill in the Employee Claim Application Form;
◇ Copy of medical record cover, copy of medical history (medical history must clearly record the date of treatment, condition, drug name, dosage form, dosage, taking method, and stamped with doctor's seal or full name);
◇ Original medical fee receipt (hospital certificate, handwritten receipt or copy of receipt is invalid), the fee items and fee date on the receipt must be consistent with the medical record;
◇ Photocopy of laboratory test and inspection report.
◇ Copy of discharge summary (hospitalization);
◇ A copy of the list of expenses during hospitalization (hospitalization);
2. Claim Settlement Instructions:
1) Cardholder medical treatment: Those who participate in social insurance payment, emergency and hospitalization must hold the social (medical) insurance card and medical records manual in accordance with the medical insurance regulations, and those who do not use medical insurance will not be paid. If the new employees seek medical treatment, the medical insurance information has not been opened during the medical treatment can only claim the personal self-financing part of the Shanghai medical insurance scope; Those who do not participate in Shanghai medical insurance can only claim the self-financed part of Shanghai medical insurance coverage;
2) If the medical receipt is lost, no claim can be made, and the copy of the hospital certificate or receipt is invalid;
3) According to the principle of insurance compensation, the compensation shall not exceed the actual loss of the compensation. If the multi-party insurance can only pay the insufficient part, the company will not pay the medical expenses already paid in other companies.
4) Outpatient and emergency medicine amount: emergency three days, outpatient seven days, chronic disease 14 days, more than the prescribed amount of medicine costs will not be reimbursed.
5) All kinds of laboratory tests and disease examinations, the inspection report should be attached when applying for compensation;
6) Prescription medicine: the hospital prescription can only be obtained in the hospital prescription, prescription or purchase of drugs, will not be reimbursed.
7) Claim validity:
◇ The commencement date is the date on which the Company receives the premium paid by your unit;
◇ The expiration date shall be calculated from the date of termination or termination of the employment relationship of the Chinese employee by the insured entity as agreed in the contract signed between you and the company;
◇ The cost of the insurance plan is moderate
7) Claim validity:
◇ The commencement date is the date on which the Company receives the premium paid by your unit;
◇ The expiration date shall be calculated from the date of termination or termination of the employment relationship of the Chinese employee by the insured entity as agreed in the contract signed between you and the company;
◇ The insurance plan fee shall be paid by the insured unit of the Chinese employee to the company on a monthly basis. If the insured unit fails to pay the fee for more than 60 days, the insurance plan shall be terminated.
Our company has a 30-day exemption period, during which the relevant expenses will not be reimbursed.
8) Time limit for claim application: under normal circumstances, claim should be applied within 60 days from the second day of medical treatment expenses, and special circumstances can be extended appropriately.
Out-of-town treatment claims
1) If you fall ill during the business trip, you should receive emergency treatment at the local county (district) level or county (district) level or above public general hospital (with emergency seal), and bring all the information to the nearest medical insurance center within one month after the end of treatment to make up the settlement procedures. With the original statement issued by the medical insurance center and a copy of the medical receipt (other materials and claims required materials) to our company to settle claims;
2) If you work in the field for a long time (more than 1 month), you need to submit the written proof of the hiring company (and stamp the official seal), and go to the district and county medical insurance for the transfer of medical relations. The expenses incurred for outpatient treatment in a public general hospital at or above the workplace shall be settled at the nearest medical insurance center according to the regulations of Shanghai Medical Insurance (within 3 months from the date of receipt issued by the medical institution), and shall be settled by our company with the original statement and a copy of the medical receipt issued by the medical insurance center (other materials and materials required for claim settlement);
Scope of no claim
1. Seek treatment in hospitals that are not covered by medical insurance and regulated by our company;
2. For those who have participated in Shanghai social insurance payment, the social (medical) insurance card and medical treatment record manual have not been used in outpatient, emergency and hospitalization;
3. Self-funded projects;
4. Dispensing medicines on behalf of patients without medical history;
5. Medical treatment that is not paid for
1) Service items
◇ Consultation fee, out-patient fee, special outpatient fee;
◇ Urgent fees for examination and treatment, special medical service fees (including nurses, escorts, follow-up visits, home visits, full mother-child service, special surgery surcharge, high quality and premium fees);
◇ Medical records, various billing costs.
2) Non-disease treatment programs
◇ A variety of beauty, bodybuilding projects and some non-functional cosmetic surgery, orthopaedic surgery, etc. (such as: treatment of freckles, acne (pimples, pimples), facial pigmentation (melasma), moles, white hair, hair transplant, ear piercing, facial mask, dental implants, mouth deformity, snoring, flat feet, scar repair;
◇ Various cosmetic, orthopedic (except poliomyelitis sequela) and physiological defect treatment (such as: armpit deodorization, cleft lip repair, stuttering, orthotropia, and multiple fingers (toes), circumcision, "Q" leg "X" leg and other surgical items);
◇ A variety of weight loss, weight gain, increase, smoking cessation and other projects;
Diagnosis of human body information, computer selection of the best pregnancy period, fetal sex and fetal development examination (except perinatal examination of female insured persons) and other diagnosis and treatment items
◇ A variety of health examinations, vaccinations;
A variety of preventive health care diagnosis and treatment items (such as preventive appendectomy, preventive tonsillectomy, etc.);
◇ Various medical consultation (including psychological consultation, health consultation, diet consultation), medical appraisal (judicial appraisal, industrial injury appraisal, labor appraisal, medical appraisal, paternity appraisal), various predictions (stroke prediction, health prediction, disease prediction) health guidance and other projects.
3) Diagnosis and treatment items and medical materials
The use of positron tomography device, electron beam, cell knife, ophthalmic excimer laser therapy equipment and other large medical equipment for examination and treatment projects;
Glasses, dentures (including post crown, set crown, mounting dentures), prosthetic eyes, prosthetic limbs, hearing AIDS and other rehabilitation equipment, a variety of self-use health care, massage, monitoring, inspection and treatment physiotherapy equipment;
◇ Implantable automatic multirate defibrillator (ICD);
◇ The price is limited to disposable medical materials that cannot be charged separately according to the department.
4) Treatment items
Organ source or tissue source for transplantation of various organs or tissues (except skin transplantation of burn patients);
Transplantation of organs or tissues other than kidney, heart valve, cornea, skin, blood vessels, bone and bone marrow, and related operations to obtain organ and tissue sources;
◇ Herniated disc
Myopia orthopedics, myopia (refractive error) examination and treatment;
Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment items;
◇ Blood therapy, cosmetic teeth cleaning, dental prostheses, dental implants, dental orthodontics, dental plaque treatment, porcelain teeth and other projects;
◇ All kinds of venereal diseases, specific infectious diseases, AIDS, mental illness, schizophrenia, sex reassignment surgery, human experimentation, artificial reproduction, contraception and sterilization treatment costs, various infertility (sterility), sexual dysfunction, tubal examination;
◇ Various painless examination (gastroscopy, colonoscopy, tracheoscopy, etc.) anesthesia fees, painless abortion anesthesia fees;
◇ Use a variety of protein preparations (drugs containing α-2β components, genetically modified seeds, sunwhite energy, etc.);
5) Others
◇ A variety of scientific research, teaching, clinical validation of diagnosis and treatment projects;
◇ All expenses incurred in violation of family planning;
All expenses arising from fighting, alcoholism, drug addiction, self-injury, self-harm, suicide, sexually transmitted diseases, pet bites, traffic accidents, medical accidents and other liability incidents;
◇ Medical expenses incurred when going abroad or to Hong Kong, Macao or Taiwan for family visits, meetings, investigation, further study or lectures;
The inpatient who should be discharged but refuses to be discharged shall be identified by the medical technical appraisal team to confirm that the inpatient treatment has been established, and the diagnosis and treatment items and all expenses incurred from the second day after the identification and confirmation; The medical treatment items and all expenses incurred by the insured personnel who are hospitalized in name or do not meet the admission standards;
◇ Medical expenses incurred for health care and unauthorized rehabilitation.
6. Scope of items for non-reimbursed medical services facilities
Referral transportation, first aid fare, outpatient medicine decocting fee, traditional Chinese medicine processing fee, meal fee, disposable items such as sheets, diapers, garbage bags and other special life service fees.
7. Taking, applying or injecting drugs without following medical advice;
8. Treatment and rehabilitation of uncured diseases and pre-existing disabilities before insurance;
9. Engaged in diving, water skiing, rafting, skiing, skydiving, rock climbing, adventure activities, martial arts competition, wrestling competition, stunt show, horse racing, racing and other high-risk sports;
10. War, military action, insurrection or armed rebellion;
11. Nuclear explosion, radiation or contamination;
12. Other non-claims or expenses incurred during the period of exemption specified in this Manual
Relevant definition
Emergency conditions refer to the following conditions that require an emergency stamp on the medical record:
◇ High fever (38.5 degrees for adults, 39 degrees for children);
Acute abdominal pain, severe vomiting, severe diarrhea;
◇ Shock of various causes;
◇ Coma;
◇ Seizures;
Severe wheezing and dyspnea;
◇ Acute chest pain, acute heart failure, severe arrhythmia;
Hypertensive crisis, hypertensive encephalopathy, cerebrovascular accident;
◇ Acute bleeding due to various reasons;
◇ Acute urinary effusion, urinary asthenia, hematomia, renal colic;
All kinds of acute poisoning (food or drug poisoning). Various accidents (electrocution, drowning, hanging, throat cutting);
Traumatic brain injury, fracture, dislocation, laceration, burn, scalding or other acute trauma;
◇ All kinds of poisonous animals, insect bites, acute allergic diseases;
Foreign bodies in the five features, respiratory tract and esophagus, acute eye pain, red or swollen eyes, sudden visual impairment and eye trauma;
◇ Diseases of infants within two months;
◇ Other critical and serious patients should be given emergency treatment.
Chronic diseases:
◇ Chronic obstructive Pulmonary disease (Bronchiectasis)
◇ Chronic pancreatitis
◇ Tuberculosis
◇ Chronic atrophic gastritis
◇ High blood pressure (Stage 2 and above)
◇ Chronic glomerulonephritis
◇ Coronary heart disease
Rheumatic heart disease
◇ Chronic pulmonary heart disease
◇ Chronic cardiac insufficiency
◇ Necrosis of the femoral head
Cerebrovascular accident (cerebral hemorrhage, cerebral thrombosis, cerebral infarction, cerebral atrophy and sequelae)
◇ Systemic lupus erythematosus
◇ Chronic viral active hepatitis
◇ Cirrhosis of the liver
◇ Aplastic anemia
◇ Chronic renal insufficiency (including uremia)
◇ Diabetes
◇ Parkinson's disease
◇ Epilepsy
◇ Malignant tumors (including outpatient radiotherapy and chemotherapy)
◇ Leprosy
◇ Rejection therapy after organ transplantation
◇ Severe burns (two degrees deep, 20% area or more)
