WHEREAS
the Certificate Holder named in the
Certificate of Insurance hereto (“the
Certificate Holder) has made to
MULTI-PURPOSE INSURANS BHD (14730-X)
(“the Company”) a declaration which shall be
the basis of this Contract and which is
deemed to be incorporated herein and has
paid the Annual or Monthly Premium, as the
case may be, stated in the Certificate of
Insurance hereto as consideration for the
insurance hereinafter contained.
In consideration of the payment of Premium
and in reliance upon the General Provisions,
Definitions, Conditions, Exclusions, and
Endorsements attached hereto that if any of
the Insured Person is confined to hospital
as a direct result of a covered Disability,
as defined herein, the Company will pay the
Benefits stated in the Schedule of Benefits
based on the actual, usual, customary and
reasonable expenses incurred under the
Policy.
Provided that no Benefits will be payable
unless the entire hospital confinement had
been recommended and approved by a legally
qualified medical practitioner. The due
observance and fulfillment by the Insured
person of the terms, and conditions
contained herein or endorsed hereon, which
terms and conditions shall form part of this
Policy, shall insofar as the context
permits, be deemed to be conditions
precedent to any liability under this
Policy.
BENEFITS
The Company agrees that
if during the Period of Insurance, the
Insured Person sustains Injury as the
result of an Accident or a Disability,
the Company will pay the Certificate
Holder as the case may be, the
appropriate benefit as stated in the
Schedule of Benefits.
1. DAILY HOSPITAL INCOME
In the event of a Confinement due to a
covered Accident, Illness, Sickness or
Disease, the Company shall pay for daily
hospital income as stated in the
Schedule of Benefits provided such
Confinement is made under the
recommendation of the attending
Physician or Surgeon. Payment for such
benefit shall not exceed an aggregate
total of one hundred twenty (120) days
of Confinement in a licensed Hospital as
the result of Any One Disability.
2. SURGICAL OPERATION CHARGES
When by reason of a Disability, the
Insured Person shall require surgery to
be performed in a Hospital, the Company
will reimburse the Reasonable and
Customary Charges for a Medically
Necessary surgery charged by the Surgeon
for a Covered Surgery (“Covered
Surgery”), subject to the terms and
conditions as set out hereunder. The
Covered Surgeries and their respective
corresponding assigned categories are
contained in the attached Surgical
Schedule, which forms an integral part
of this policy. The benefit payable
hereunder includes pre-surgical
assessment, Surgeon’s visits and all
normal post-surgical care up to 31 days
inclusive both before and after the
operation, not exceeding the limits as
set forth in the Schedule of Benefits.
The Surgeon's fees shall also include
those fees charged by a second Physician
or Surgeon who may be consulted prior
and during Hospitalisation of the
Insured Person for a Covered Surgery.
The benefit payable per Disability is
expressed in the table below as a
percentage of the maximum limit
specified in the Schedule of Benefits or
any Endorsement attached to this policy
and may vary according to the category
of Surgery as set out in the Surgical
Schedule.
Category of Covered Surgery & % of
Benefit Payable
| Category |
% of
Surgery Benefit Sum Assured |
| Category 1 |
100% |
| Category 2 |
60% |
| Category 3 |
40% |
| Category 4 |
20% |
The above benefit is
subject to the following terms and
conditions (“surgical terms & conditions”):
-
-
The Covered Surgery
must qualify as Medically Necessary for
the benefit to be payable by the
Company.
-
The Insured Person is
considered to have suffered a
Disability, if, after having reviewed
the medical and other evidence required
by the Company, it is the opinion of the
Company that the Insured Person has
suffered from a Disability. The decision
of the Company will be final.
-
Where multiple
Surgeries are performed during a
twenty-four (24) hour period, a single
Surgical Benefit will be payable, based
on the category that pays the most.
-
All Surgical Benefit
claims must be evidenced and supported
by original hospital admission/discharge
certification and breakdown of surgical
bill(s).
3. ADDITIONAL MAJOR
SURGERY
If, in relation to a Disability, the
coverage benefit afforded to the Insured
Person under the Surgical Operation Charges
benefit has been exhausted, the Company will
reimburse the Reasonable and Customary
Charges payable for such Additional Major
Surgery for a Covered Surgery which is
categorised as Category 1 or Category 2 in
the attached Surgical Schedule, subject to
the maximum limits provided under the
Schedule of Benefits. The surgical terms &
conditions as in the Surgical Operation
Charges shall similarly apply in relation to
this Benefit.
4. EMERGENCY ACCIDENTAL OUTPATIENT
TREATMENT
The Company will reimburse the Reasonable
and Customary Charges incurred for up to the
maximum stated in the Schedule of Benefits,
as a result of a covered bodily injury
arising from an Accident for Medically
Necessary treatment as an outpatient at any
registered clinic or hospital within 24
hours of the Accident causing the covered
bodily Injury. Follow up treatment by the
same doctor or same registered clinic or
Hospital for the same covered bodily injury
will be provided up to 14 days and the
maximum amount as set forth in the Schedule
of Benefits.
5. HOME NURSING – (max 30 days following
discharge from hospital)
Reimbursement of Reasonable and Customary
Charges of full-time services of a
registered Nurse for services rendered to
the Insured Person who is medically
necessary and prescribed by the attending
Physician or Surgeon for the continued
treatment at the Insured Person’s home of
the specific medical condition for which the
Insured Person was hospitalised. Services
for activities of daily living that are not
medically necessary will not be payable. The
benefit shall be payable up to a maximum
period as set forth in the Schedule of
Benefits. The Insured Person, however, is
required to provide evidence, at its cost
and expense, of the continuance of such
necessity if required by the Company.
6. AMBULANCE FEES
Reimbursement of the Reasonable and
Customary Charges incurred for necessary
domestic ambulance services inclusive of
attendant to and/or from the Hospital of
confinement. Payment will not be made if the
Insured Person is not hospitalised and
subject to the limits as set forth in the
Schedule of Benefits.
For detailed
information, Please refer to
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