+ Certified Plan

Benefit Items¹		Maximum Benefit Limit（HK$）
Plan Level		Worldwide^2,3,4/ Asia & Australia – New Zealand^4,5,6,7
Deductible⁸ (per policy year) I. Basic Benefits: benefit items (a) – (l); and II. Enhanced Benefits: benefit items (a) – (b), (c1) – (c2) and (d) – (n)		0/ 20,000/ 40,000/ 80,000
Designated Ward Class⁹		•Semi-private Room: For confinement in Hong Kong, Macau or Mainland China •Private Room: For confinement outside Hong Kong, Macau or Mainland China
I. Basic Benefits
a.	Room and Board	Full cover¹⁴
b.	Miscellaneous Charges
c.	Attending Doctor’s Visit Fee
d.	Specialist’s Fee¹⁰
e.	Intensive Care
f.	Surgeon’s Fee
g.	Anaesthetist’s Fee
h.	Operating Theatre Charges
i.	Prescribed Diagnostic Imaging Tests^10,11
j.	Prescribed Non-surgical Cancer Treatments¹²
k.	Pre- and Post-confinement/ Day Case Procedure¹³ Outpatient Care¹⁰
	• 2 prior outpatient visits or emergency consultations per confinement/ day case procedure
	• All related follow-up outpatient visits per confinement/ day case procedure (within 90 days after discharge from hospital or completion of day case procedure)
l.	Psychiatric Treatments^2,6(per policy year)	60,000
II. Enhanced Benefits¹⁵
a.	Outpatient Kidney Dialysis¹⁰	Full cover¹⁴
b.	Rehabilitation Treatment¹⁰(per day) Maximum 90 days per policy year (within 90 days after discharge from hospital)	1,800
c.	Stroke Rehabilitation Treatment
	(1) Home Facility Enhancement Benefit¹⁰(per incident)	80,000
	(2) Stroke Ancillary Benefit¹⁰(per visit) 1 visit per day, maximum 30 visits per policy year and maximum HK$100,000 per incident	1,000
	(3) Disability Subsidy Benefit (per month) Maximum 24 months per incident	7,500
d.	Emergency Outpatient Treatment	Full cover¹⁴
e.	Emergency Outpatient Dental Treatment
f.	Hospital Companion Bed
g.	Registered Private Nurse’s Fees¹⁰ Maximum 120 days per policy year
h.	Post-confinement Home Nursing¹⁰ Maximum 196 days per policy year (within 196 days after discharge from hospital following surgery or admission to intensive care unit)
i.	Post-confinement/ Day Case Procedure¹³ Chinese Medicine Practitioner Outpatient Care (per visit) 1 follow-up outpatient visit per day, maximum 15 follow-up outpatient visits per confinement/ day case procedure (within 90 days after discharge from hospital or completion of day case procedure)	600
j.	Reconstructive Surgery¹⁰ (per accident/ mastectomy)	180,000
k.	Medical Appliance for Reconstructive Surgery Each item per policy year	100,000
l.	Donor’s Benefit (applicable in Hong Kong) (For transplantation of heart, kidney, liver, lung or bone marrow in Hong Kong only)	30% of total transplantation cost
m.	Hospice Care (per policy year)	100,000
n.	Pregnancy Complications (per policy year) Waiting period: 12 months	180,000
o.	Sleep Apnea Treatment¹⁰(per sleep apnea diagnosis) Waiting period: 24 months	10,000
III. Other Benefits¹⁵ Available for policies with HK$0 deductible¹⁶
a.	Outpatient Surgery¹⁷Cash Allowance (per day case procedure¹³)	2,400
b.	Hospital Cash Benefit (per day) Maximum 60 days per policy year	1,600
c.	Cash Benefit for Top-up Subsidy¹⁸(per day of confinement) Maximum 60 days per policy year	1,200
IV. Other Limits
Annual Benefit Limits For all benefit items of I. Basic Benefits, II. Enhanced Benefits, and III. Other Benefits		10,000,000
Lifetime Benefit Limits For all benefit items of I. Basic Benefits, II. Enhanced Benefits, and III. Other Benefits		48,000,000

+ Remarks

Unless otherwise specified, eligible expenses incurred in respect of the same item shall not be recoverable under more than one benefit item of the Benefit Schedule.

There is no geographic limitation for “Worldwide”, except for Psychiatric Treatments and Donor’s Benefit (applicable in Hong Kong) which apply to Hong Kong only.

For a “Worldwide” plan, the benefits payable for non-emergency treatments received in Canada or the United Kingdom will be reduced to 60% when the insured person of the same policy has stayed in that location for an aggregate of 6 months or more in the past 12 consecutive months immediately before his/ her receiving such non-emergency treatment. Such reduction applies to benefit items (a) to (k) of I. Basic Benefits, benefit items (a) to (c), (f) to (k), and (m) to (o) of II. Enhanced Benefits as specified in the Benefit Schedule.

Insured persons who have resided or have stayed/ studied in the United States or Europe (except the United Kingdom) for 6 months or more in the past 12 months, or insured persons planning to reside, stay or study in the United States or Europe (except the United Kingdom) in the next 12 months, are only eligible to select “Asia & Australia-New Zealand” as the plan level.
Upon policy renewal, Blue Cross reserves the right to change the plan level from “Worldwide” to “Asia & Australia-New Zealand” if the place of residence of the insured person has changed to the United States or Europe (except the United Kingdom).

“Asia & Australia-New Zealand” shall mean Afghanistan, Australia, Bangladesh, Bhutan, Brunei, Cambodia, Hong Kong, India, Indonesia, Japan, Kazakhstan, Kyrgyzstan, Laos, Macau, Mainland China, Malaysia, Maldives, Mongolia, Myanmar, Nepal, New Zealand, North Korea, Pakistan, the Philippines, Singapore, South Korea, Sri Lanka, Taiwan, Tajikistan, Thailand, Timor-Leste, Turkmenistan, Uzbekistan and Vietnam.

All benefit items listed in the Benefit Schedule are applicable to the cover area of “Asia & Australia-New Zealand”, except for Psychiatric Treatments and Donor’s Benefit (applicable in Hong Kong) which apply to Hong Kong only.

For emergency treatments received outside “Asia & Australia-New Zealand”, Blue Cross will reimburse the eligible expenses and/ or other expenses incurred in accordance with the Terms and Benefits for the plan level “Asia & Australia-New Zealand”.
For non-emergency treatments received outside “Asia & Australia-New Zealand”, Blue Cross will reimburse the eligible expenses and/ or other expenses incurred in accordance with the Benefit Schedule attached to the Terms and Benefits of the VHIS Standard Plan published by the government of Hong Kong.

Deductible applies to all the benefit items under I. Basic Benefits and II. Enhanced Benefits (except Disability Subsidy Benefit under Stroke Rehabilitation Treatment and Sleep Apnea Treatment) as specified in the Benefit Schedule. Subject to the maximum benefit limit for the corresponding benefit items listed in the Benefit Schedule, if the customer has chosen a deductible other than HK$0, Blue Cross will reimburse the eligible expenses incurred in excess of the deductible which is borne by the customer; while 100% of the eligible expenses incurred will be paid by Blue Cross if HK$0 deductible applies.

If the insured person is voluntarily confined to a level of hospital facilities and services higher than the designated ward class as specified in the Benefit Schedule, the eligible claims made will be calculated based on below scale of reimbursement:

Designated Ward Class	Actual Confined Ward Class	Reimbursement Percentage of All Eligible Claims
Semi-private Room	Private room	50%
Semi-private Room	Any ward class above private room	25%
Private Room	Any ward class above private room	25%

The reduced benefits payable after applying this scale of reimbursement shall not be less than the benefits payable in accordance with the Benefit Schedule attached to the Terms and Benefits of the VHIS Standard Plan published by the government of Hong Kong.

This scale of reimbursement shall not be applied if the insured person is confined in a room at a higher level ward class resulting from:
(a)		unavailability of a designated or lower ward class due to room shortage at the hospital for emergency treatment;
(b)		confinement in isolation that requires a specific ward class; or
(c)		any other reason not involving the policyholder and/ or insured person’s own individual preference for the confined ward class.

10.

Blue Cross shall have the right to ask for proof of recommendation e.g. written referral or testifying statement on the claim form by the attending doctor or registered medical practitioner.

11.

Tests covered here only include computed tomography (“CT” scan), magnetic resonance imaging (“MRI” scan), positron emission tomography (“PET” scan), PET-CT combined and PET-MRI combined.

12.

Treatments covered here only include radiotherapy, chemotherapy, targeted therapy, immunotherapy and hormonal therapy.

13.

“Day Case Procedure” shall mean a medically necessary surgical procedure for investigation or treatment to the insured person performed in a medical clinic, or day case procedure centre or hospital with facilities for recovery as a day patient.

14.

Full cover shall mean no itemised benefit sublimit, and the actual amount of eligible expenses and other expenses payable in accordance with the Terms and Benefits, which shall be subject to the annual benefit limit and lifetime benefit limit. Please refer to the Benefit Schedule for items eligible for full cover.

15.

Please refer to the Supplement for the terms and conditions applicable to these benefit items.

16.

These benefit items are not available for a policy with HK$20,000/ HK$40,000/ HK$80,000 deductible.

17.

Only applicable to the following day case procedures: oesophagogastroduodenoscopy, colonoscopy, cystoscopy, arthroscopy, colposcopy, bronchoscopy, repair of retinal detachment and hysteroscopy.

18.

For an insured person who is confined in a hospital and the eligible expenses incurred by such confinement are partly or fully paid by any other hospital reimbursement plans offered by a licensed insurance company other than Blue Cross (regardless of whether it is an individual or group policy), if the eligible expenses reimbursed would have been payable under the terms and benefits of the Certified Plan, Blue Cross will pay the Cash Benefit for Top-up Subsidy for each day of confinement.

19.

If the policyholder has taken out other insurance coverage besides the Certified Plan, the policyholder shall have the right to claim under any such other insurance coverage or the Certified Plan. However, if the policyholder or the insured person has already recovered all or part of the expenses from any such other insurance coverage, Blue Cross shall only be liable for such amount of eligible expense, if any, which is not compensated by any such other insurance coverage.
Reasonable and Customary refers 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 Blue Cross in utmost good faith. The Reasonable and Customary charges shall not in any event exceed the actual charges incurred. In determining whether a charge is Reasonable and Customary, Blue Cross shall make reference to the following (if applicable): (a) treatment or service fee statistics and surveys in the insurance or medical industry; (b) internal or industry claim statistics; (c) gazette published by the government; and/ or (d) other pertinent source of reference in the locality where the treatments, services or supplies are provided.
Medically Necessary refers to 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: (a) require the expertise of, or be referred by, a registered medical practitioner; (b) be consistent with the diagnosis and necessary for the investigation and treatment of the disability; (c) 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; (d) 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 (e) be furnished at the most appropriate level which, in the prudent professional judgment of the attending registered medical practitioner, can be safely and effectively provided to the insured person.

Notes:

1.		The above information does not contain the full terms of the policy and is for reference only. Both English and Chinese versions are official versions and neither one shall prevail over the other. Any inconsistency shall be interpreted in favour of the policyholder. Please refer to the policy for the exact terms and conditions and the full list of policy exclusions.
2.		The above product(s) is/are offered for sale in Hong Kong only and is/are underwritten by Blue Cross (Asia-Pacific) Insurance Limited, an authorised insurer in Hong Kong.

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