AXA Affin

General Insurance Berhad

OS HRS SDN BHD

Policy Number : 04326480

Period of Insurance : 01/03/2018 to 28/02/2019

DISCLAIMER: This document is confidential; its contents do not constitute a commitment by AXA Affin General Insurance

Berhad except where provided for in a written agreement between you and AXA Affin General Insurance Berhad. Any

unauthorized disclosure, use or dissemination, either whole or partial, is prohibited. If you are not the intended recipient this

document please notify the sender immediately.

Contents

2

1. Policy Coverage – Outpatient

2. Outpatient Workflow

3. Outpatient Policy Exclusions

4. Policy Coverage – Inpatient

5. Admission & Discharge Workflow

6. Panel Hospitals

7. Inpatient Policy Exclusions

8. Reimbursement Process

9. Q & A

Policy Coverage – Outpatient

Schedule of Benefits – Outpatient

SCHEDULE OF BENEFITS PLAN

(RM)

1

OUTPATIENT GP TREATMENT

at AXA Panel Clinics

Routine Consultation

Medication

Injection

Diagnostic Lab / X - Ray Procedure

Out-patient Surgical Procedures

Limit per visit Unlimited

Number of Visit per year per insured Unlimited

Copayment Nil

Overseas Treatment (Limit per visit- RM) 50

2

OUTPATIENT SPECIALIST TREATMENT

With Panel GP Referral

Consultation

Medication

Injection

Diagnostic Lab / X - Ray Procedure

Out-patient Surgical Procedures

Limit per visit Unlimited

Number of Visit per year per insured Unlimited

Copayment Nil

Limit per Annum 1,200

Overseas Treatment (Limit per visit- RM)150

(Without GP Referral)

This includes long term medication for below Chronic Illnesses :

Chronic illnesses such as Diabetes, High Blood Pressure, Asthma, Hepatitis B and C

Carriers, nerve disorders or degenerative diseases, endometriosis, transverse myelitis

and conditions arising there from or associated therewith.

Subject to following:

All insured members are to seek treatment at panel GP

Drugs prescribed for use within one (1) month after treatment from GP

Outpatient (Clinical) Benefits

Outpatient Workflow

Any plan enquiry related to medical coverage, please contact MiCare at

Hotline : 1 300 88 9979

Email : callcenter@micaresvc.com

NEW DECAL

Cashless Medical Card

Clinic nurse verifies name

against on-line real time

MiCARE system

Patient enjoys Cashless Visit

by collecting medication

without any payment.

Patient signs

Medical Record of

Attendance

Patient arrives at clinic,

present Medical Card

Patient seeks

consultation

Caution:

Patient is required to make

payment when the claim has

exceeded the entitlement (if any)

Outpatient GP Flow Chart

Before the appointment, call

the 24/7 Call Centre for a

Guarantee Letter. Fax over

the referral letter

Alternatively, the hospital

can contact us with

Outpatient Claim Form

Our Call Center validates

& authenticate info, issues

Guarantee Letter within 1

hour upon receipt of

relevant documents

Patient obtained

appointment date for

Specialist visit upon receipt

of Referral Letter from Panel

Clinic

Patient seeks

consultation

Outpatient specialist

clinic/hospital receives

Guarantee Letters

Patient enjoys Cashless Visit by

collecting medication without

any payment required. However,

patient may be required to pay

for uncovered charges.

Outpatient SP Flow Chart - Cashless

Outpatient Policy Exclusions

• More than one (1) Outpatient Consultation per day to a General Practitioner or

Specialist.

• Vitamins, Food Supplement, Herbal Cures, Anti Obesity/Weight Reducing

Agents including off the counter medications.

• Investigation and Treatment of sleep and snoring disorders.

• Private nursing care and house calls by doctors for any reasons.

• Hormone therapy

• Contraceptive medications and devices, sterilisation procedures, Treatment for

complications, reversal of such procedures and the work up or Treatment of

sexual dysfunction or infertility.

• Any circumcision unless Medically Necessary.

Policy Exclusions

• Investigation and Treatment relating to pregnancy including prenatal,

childbirth, postnatal and all complications arising therefrom.

• Conditions related to sexually transmitted Disease, AIDS and AIDS

Related Complex or its sequel.

• Preventive Vaccinations / Immunisations except for the following that

are applicable to eligible Children only (subject to Outpatient Benefit

limit, if any):

Policy Exclusions

BCG (booster);

Hepatitis B (infants up to 1 year old);

Triple Antigen & TetrAct Hib (infants up to 1 year old);

Double Antigen (booster), including Oral Polio;

MMR;

Rubella

Note: This list is non-exhaustive. Please refer to the policy contract for the terms and conditions under this policy.

Policy Coverage – Inpatient

Schedule of Benefits – Inpatient

TABLE OF BENEFITS PLAN RB350 PLAN RB200

1 Hospital Room & Board (Daily max up to 180 days) 350 200

2 Intensive Care Unit (Daily max up 30 days)

Full Reimbursement subject to Overall Limit provided the

charges are within the recommendation of the MMA

Guidelines and Reasonable and Customary Charges

3 Hospital Supplies and Services

4 Surgeon Fee

5 Anaesthetist Fee

6 Operating Theatre Charges

7Daily In-Hospital Physician’s Visit

(Max. 180 days)

8Pre-Hospital Diagnostic Tests

(within 60 days before hospital confinement)

9Pre-Hospitalisation Specialist Consultation

(within 60 days before hospital confinement)

10Second Surgical Opinion

(within 60 days before hospital confinement)

11Post-Hospitalisation Treatment

(within 60 days from hospital discharge)

12Emergency Accidental Outpatient Treatment

(within 24 hours after the accident & follow-up up to 60 days)

13Accidental Dental Treatment

(within 24 hours after the accident & follow-up up to 14 days)

14 Daycare Procedure

15 Ambulance Charges (by road)

16 Annual Outpatient Cancer Treatment

17 Annual Outpatient Kidney Dialysis Treatment

18 Goods and Services Tax

19 Government Hospital Daily Cash Allowance (Max. 180 days) 200 100

20 Emergency Sickness Treatment (10pm - 8am) 100 100

21 Medical Report Fee Reimbursement 80 80

OVERALL ANNUAL LIMIT 80,000 40,000

22 Funeral Expenses 10,000 10,000

Admission & Discharge Workflow

For emergency, please proceed to Emergency Department

in the hospital. Hospital will stablised member before going

through normal admission procedure.

a) Non Elective / Non Pre-Planned:

Member to produce IC, Admission

Letter & Medical Card to the

admission counter

b) Elective / Pre-Planned:

Member to present the IC,

Medical Card & Admission Letter

to the admission counter.

(Please inform on the actual

admission date and request for

Pre-Planned arrangement)

a) Hospital verifies card and name

via our 24x7 call center / web-

system

b) Hospital will assist to prepare

relevant documents & medical

reports

Hospital faxes relevant

documents with Admission

Request Form

a) Call Center validates & authenticate info,

issues Guarantee Letter or Decline

Letter within 1 hour upon receipt of

relevant documents

b) Call Centre validates info, issues Pre-

Approved GL or Decline Letter within 1

hour upon receipt of relevant

documents. Member to contact Call

Centre / Hospital on the status of

Guarantee Letter.

a) Member gets admitted into hospital

b) Member proceed to the admission counter

and pre-approved GL is ready for

member’s admission

213

4

Admission to Panel Hospital

Patient ready to be

discharged

Hospital prepares

itemized bills and gathers

all relevant reports

Hospital faxes

itemize bills and all

relevant reports

Our Call Center validates,

audits & processes bills from

hospital, issues Final

Guarantee Letter within 1

hour upon receipt of full

documents from hospital

Hospital receives

Final Guarantee

Patient pays for

uncovered charges

(if any)

Patient

discharged

Discharge from Panel Hospital

Examples of non-covered items:

• Diagnostics tests that are not related to the disability during the admission

• Extra food

• Admission kit / inpatient kit / discharge pack

• Laundry, flask, extra toilet roll, tissue paper

• Newspapers, rental of television, telephone charges, electricity and similar

facilities

Ineligible Expenses

Panel Hospitals

Panel Hospitals – Klang Valley

Alpha Specialist Centre (Day Care)

Ara Damansara Medical Centre

Assunta Hospital Beacon Hospital BP Specialist Centre - Taman

Megah Columbia Asia Hospital - Bukit

Rimau Columbia Asia Hospital –

Klang Columbia Asia Hospital -

Petaling Jaya Columbia Asia Hospital -

Puchong DEMC Specialist Hospital Hospital Islam Az-Zahrah Hospital Pakar An-Nur Hospital Umra Kajang Plaza Medical Centre Kelana Jaya Medical Centre KPJ Ampang Puteri Specialist

Hospital KPJ Damansara Specialist

Hospital KPJ Kajang Specialist Hospital KPJ Klang Specialist Hospital KPJ Rawang Specialist Hospital KPJ Selangor Specialist

Hospital

KPMC Puchong Medical Centre

Manipal Hospitals Klang (Formely known as Arunamari Specialist Medical Centre)

Pantai Hospital Klang Pusat Pakar Mata Centre for

Sight (Day Care) Putra Medical Centre - Sungai

Buloh QHC Medical Centre Regen Specialist Centre (Day

Care) SALAM Shah Alam Specialist

Hospital Sentosa Specialist Hospital -

Klang Sri Kota Specialist Medical

Centre Subang Eye Specialist Centre

(Day Care) Subang Jaya Medical Centre

Sungai Long Medical Centre Sunway Medical Centre

The Tun Hussien Onn National Eye Hospital

Tropicana Medical Centre UITM Private Specialist Centre USJ Eye Specialist (Day Care)

Selangor

Cardiac Vascular SentralKuala Lumpur

Centre For G. I & Liver Disease (CENGILD)

Columbia Asia Hospital -Cheras

Columbia Asia Hospital -Setapak

Damai Service Hospital (HQ) - Jalan Ipoh

Gleneagles Kuala Lumpur Global Doctors Hospital Hospital Aman - Jalan

Ipoh Hospital Pakar Al-Islam Hospital Pusrawi iHeal Medical Centre

Institut Jantung Negara International Specialist

Eye Centre (Day Care) KL Eye Specialist Centre

(Day Care) Kuala Lumpur Sports

Medicine Centre KPJ Tawakkal Specialist

Hospital Life Care Diagnostic

Medical Centre

Lourdes Medical Centre Pantai Hospital Ampang Pantai Hospital Cheras Pantai Hospital Kuala

Lumpur Parkcity Medical Centre Prince Court Medical

Centre Quill Orthopaedic

Specialist Centre Sentosa Medical Centre -

Jalan Chemur Sentul Medical Centre Taman Desa Medical

Centre Tung Shin Hospital Rampai Puteri Medical

Centre UKM Specialist Centre

UM Specialist Centre

Kuala Lumpur

Panel Hospitals – Northern

Adventist Medical Centre (formerly known as Tanjung Medical Centre)

Bagan Specialist Centre Carl Corrynton Medical

Centre (formerly known as Tropicana Medical Centre)

Gleneagles Penang Hope Children Hospital ISEC Specialist Eye Centre

Penang (Day Care) Island Hospital

KPJ Penang Specialist Hospital

Lam Wah Ee Hospital Loh Guan Lye Specialists

Centre Mount Miriam Hospital Pantai Hospital Penang Penang Adventist Hospital

Penang

Anson Bay Medical Centre Apollo Medical Centre

Columbia Asia Hospital -Taiping

Hospital Fatimah KMC Medical Centre

(Formerly known as Kinta Medical Centre)

KPJ Ipoh Specialist Hospital

Pantai Hospital Ipoh Pantai Hospital Manjung

Perak Community Specialist Hospital

Sri Manjung Specialist Centre

Taiping Medical Centre

Perak

Amanjaya Specialist Centre Kedah Medical Centre

Metro Specialist Hospital Pantai Hospital Sungai Petani Putra Medical Centre - Alor Star

Kedah

Panel Hospitals – Southern

Columbia Asia Hospital - Iskandar Puteri (Formerly Knows as Columbia Asia Hospital - Nusajaya)

Gleneagles Medini Hospital Hospital Penawar Hospital Penawar Pandan City Kempas Medical Centre Kluang Utama Specialist Hospital KPJ Bandar Maharani Specialist Hospital KPJ Johor Specialist Hospital

Medical Specialist Centre - Wisma Maria Pantai Hospital Batu Pahat Pasir Gudang Specialist Hospital Puteri Specialist Hospital - Johor Bahru Putra Specialist Hospital - Batu Pahat Regency Specialist Hospital

Johor

Mahkota Medical CentreOriental Melaka Straits Medical Centre Pantai Hospital Ayer Keroh Putra Specialist Hospital - MelakaSouthern Specialist Eye Centre (Day Care)

Melaka

Columbia Asia Hospital - Seremban KPJ Seremban Specialist Hospital Mawar Medical Centre (Formerly

known as Mawar Renal Medical Centre)

Nilai Medical Centre (formerly known as NCI Hospital)

NSCMH Medical Centre (Negeri Sembilan Chinese Maternity Hospital and Medical Centre)

SALAM Senawang Specialist Hospital

Negeri Sembilan

Panel Hospitals – East Coast

Darul Makmur Medical Centre Hospital Pakar PRKMUIP IIUM Medical Specialist Centre KCDC Hospital KPJ Pahang Specialist Hospital

(Formerly Knows as KPJ KuantanSpecialist Hospital)

Kuantan Medical Centre

Pahang

Kuala Terengganu Specialist Hospital SALAM Specialist Hospital Kuala

Terengganu

Terengganu

Kota Bharu Medical Centre Perdana Specialist Hospital

Kelantan

Panel Hospitals – East Malaysia

Bintulu Medical Centre Borneo Medical Centre Columbia Asia Hospital - Bintulu Columbia Asia Hospital - Miri ISEC Specialist Eye Centre Sibu (Day Care) Kuching Specialist Hospital

Miri City Medical Centre Normah Medical Specialist Centre Rejang Medical Centre Sibu Specialist Medical Centre Timberland Medical Centre

Sarawak

Damai Specialist Hospital - Kota Kinabalu Gleneagles Kota Kinabalu Jesselton Medical Centre KPJ Sabah Specialist Hospital (formerly

known as Sabah Medical Centre)

Rafflesia Medical Centre Tawau Specialist Hospital

Sabah

Deposit

Some hospitals may require Personal Deposits (on top of treatment deposit granted by AXA) upon admission to pay excess or non-covered items under the policy. This deposit is refundable upon discharge.

This Deposit amount may vary, e.g. RM 300 / RM 500, depending on type of treatment.

Inpatient Policy Exclusions

27

Waiting Period30 days

Specified Illness - 120 days

Pre-Existing Conditions – 12 months

Schedule of Basic Medical Coverage

(Hospitalization & Surgical Benefit)

28

1. Any medical or physical conditions arising within the first thirty (30) days from the Insured Person’s coverage effective date or reinstatement date whichever is latest except for accidental injuries.

2. Specified IllnessNo benefits shall be payable for hospitalization, surgery and/or charges incurred which are caused directly or indirectly by Specified Illnesses and its related complications.

“Specified Illnesses” shall mean the following disabilities and its related complications, occurring within the first 120 days of insurance of the insured member:

(a)Hypertension, diabetes mellitus and Cardiovascular disease(b)All tumors, cancers, cysts, nodules, polys, stones of the urinary system and biliary

system(c) All ear, nose (including sinuses) and throat conditions(d)Hernias, hemorrhoids, fistulae, hydrocele, varicocele(e)Endometriosis including disease of the Reproduction system(f) Vertebro-spinal disorders (including disc) and knee conditions

Waiting Period –

Existing and New Employees & Dependents

Policy Exclusions

Plastic/Cosmetic surgery, circumcision, eye examination, glasses,acquisition of external prosthetic appliances or devices such as artificiallimbs, hearing aids, implanted pacemakers, lens (except for basic lens)and prescriptions thereof.

Dental conditions including dental treatment or oral surgery exceptas necessitated by Accidental Injuries to sound natural teeth occurringwholly during the Period of Insurance.

Private nursing, rest cures or sanitaria care, illegal drugs,intoxication, sterilization, venereal disease and its squeal, AIDS or ARC(AIDS Related Complex) and HIV related diseases and anycommunicable diseases required quarantine by law.

Policy Exclusions

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

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

Pregnancy, child birth (including surgical delivery), abortion and prenatal or postnatal care and surgical, mechanical or chemical contraceptive methods of birth control or treatment related to impotence or sterilization.

Hospitalisation 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.

Policy Exclusions

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

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.

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

Expenses incurred for sex changes.

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

Policy Exclusions

Investigation and treatment of sleep and snoring disorders, hormone replacement therapyand alternative therapy such as treatment, medical service or supplies, including but notlimited to chiropractic services, acupuncture, acupressure, reflexology, bone setting,herbalist treatment, massage or aroma therapy or other alternative treatment.

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

Policy Exclusions

Sickness or injury arising from illegal activities and playing professional sports or from

racing of any kind (except foot racing), hazardous sports such as but not limited to:

Base jumping, cliff diving, flying in an unlicensed aircraft or as a learner, martial arts,

free climbing, mountaineering with or without ropes, water skiing, scuba diving to a

depth of more than 10 metres, trekking to a height of over 2,500 metres, bungee

jumping, canyoning, hangliding, paragliding or microlighting, parachuting, potholing,

skiing off piste or any other winter sports activity carried out off piste.

Policy Exclusions

Cosmetic (aesthetic) surgery or treatment, or any treatment which relates to or is neededbecause of previous cosmetic treatment. However we will pay for reconstructive surgery if:

(a) It is carried out to restore function or appearance after an accident or following surgery for amedical condition, provided that member has been continuously covered under a plan ofours since the accident or surgery happened; and

(b) It is done at a medically appropriate stage after the accident or surgery; and

(c) We agree to the cost of the treatment in writing before it is done.

Note: This list is non-exhaustive. Please refer to the policy contract for the terms and conditions under this policy.

BEFORE AFTER

Reimbursement Process

Claim ProcedureReimbursement Basis

Situations whereby you have to pay the hospital expenses first and file claim with us :

Admission to Non-Panel Hospitals

Hospitalisation outside Malaysia (overseas)

Emergency Accidental Outpatient Treatment

Accidental Dental Treatment

Emergency Sickness Treatment

Pre – Hospitalisation

Second Surgical Opinion

Outpatient Kidney Dialysis Treatment

Claim ProcedureReimbursement Basis

Complete the Claim Form:

• page 1 by claimant

• page 2 by doctor.

Submit ORIGINAL:

• hospital bills, itemised bills

• receipts

• test reports

Submit claim DOCUMENTS:

• within 30 days of completion of the event

Claim cheque will be ready within 14 working days upon submission of complete documentation.

(Claim forms can be obtained

from www.axa.com.my)

How to fill up the Claim Form

The insured to complete name, NRIC No, name of policyowner and

details such as date of birth, sex and contact no.

If you had an accident, please complete Part C. ACCIDENT

Please state date, time, place and how the accident happened.

How to fill up the Claim Form

If you fell sick, please complete Part D. SICKNESS

Please state nature of your illness, date first began and date first treated by a doctor.

Mandatory column on Part F. INSURED’S BANK DETAILS & Part G. AUTHORISATION TO

RELEASE INFORMATION. If the patient/covered person is a child, the insured/policyholder

should sign the statement of consent.

How to fill up the Claim Form

Email notification for successful e-banking

Claim ProcedureReimbursement Basis

The attending doctor to complete the medical report.

Claim ProcedureReimbursement Basis

Sample of Hospital Bills

Sample of Itemized Bills

Sample of Official Receipt

Thank You