尊敬的客户，您好:  
Dear Valued client:  
为了更好地保障您在遭受意外伤害或患病时的经济利益，本公司为您在平安健康保险股份有限公  
司上海分公司（以下称保险公司）投保了人身意外保险和医疗保险。本福利保障手册介绍了上述两类  
保险的主要内容及有关索赔程序，以确保您获得良好的售后服务。在您充分享受福利的同时，也请您  
仔细阅读该指引手册。  
To ensure the employees’ benefit while suffering from accident or diseases, we  
purchases AD&D and Health Insurance from Ping An Health Insurance Company of China  
(Ping An) . This Hand book aims to give detailed description on Insurance Benefit, Coverage  
and Claim Services for you.  
本手册仅作为服务指南，如该手册内容与保险条款及双方签订的协议有歧义或者相违背的地方，  
以条款或者投保人与保险人签订的协议为准。  
This Service Handbook should serve as a guide on how to use your health plan. If there  
are any discrepancies between this Service Manual and the Ping An Group Health Insurance  
Policy, the Ping An Group Health Insurance Policy shall prevail.  
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投保须知 APPLICATION NOTICE.......................................................................................................................3  
联系我们 CONTACT US.......................................................................................................................................3  
重要提示 IMPORTANT NOTES ..........................................................................................................................4  
1
、预授权 PRE-AUTHORIZATIO......................................................................................................................................4  
、特定医院 SPECIFIED HOSPITAL ..................................................................................................................................6  
2
保障方案 BENEFIT PLAN ..................................................................................................................................11  
就诊及理赔须知 TREATMENT AND CLAIM NOTICE .....................................................................................19  
1、指定医院 DESIGNATED HOSPITALS ........................................................................................................................ 19  
2、驻点医院列表 REPRESENTATIVE HOSPITAL LIST ..................................................................................................... 20  
3、理赔须知.............................................................................................................................................................. 21  
CLAIM NOTICE ...................................................................................................................................................... 22  
常见问题解答 FAQ..............................................................................................................................................23  
责任免除 EXCLUSIONS .....................................................................................................................................24  
伤残程度与给付比例表 DISABILITY LEVEL& REIMBURSEMENT SCHEDULE..............................................32  
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投保须知 Application notice  
1
、初次投保时需要提供信息：姓名、身份证号码/护照号码、理赔银行卡号、开户行全称  
First application can only be processed with information including: name,  
ID number/passport number, bank account number, bank name.  
2
、当月投保付款，当月 1 日保单生效后员工可以开始诊病，递交理赔材料。  
After premium is paid, the policy will be effective since the 1st of next month and claim  
cases can be processed.  
3
、投保时年龄在 18-65 周岁，能正常工作、劳动和生活的团体全职在职员工可作为主被保险人  
参保；其 18-65 周岁能正常工作、劳动和生活的配偶可以作为连带被保险人参保。主被保险人及其配  
偶可续保至 70 周岁；主被保险人 19 周岁以下（含）的子女（全日制学校学生至 23 周岁且未婚）可  
以作为连带被保险人参保。  
A healthy, work-able, full-time member of staff, aged 18- 65 may be the primary Insured. If  
the spouse of the primary Insured, aged 18-65, is healthy and work-able, he/she may be Insured as a  
dependant. Both the primary Insured and his/her spouse may renew this policy until he/she reaches  
7
0 full years of age. If the child of the primary Insured is under 19 full years of age; unmarried or a  
full-time student under 23 full years of age, then he/she may be insured as a policy dependent.  
联系我们 Contact us  
中文 400-8833-663 转 1  
English 400-8833-663 ext 2  
24 小时双语服务，全年无休 24/7/365 bilingual services  
预授权获取 Pre-authorization application  
医院信息查询 hospital info enquiry  
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重要提示 Important notes  
1
、预授权 Pre-authorizatio  
若您在接受以下治疗前，请拨打 400-8833-663 转 1 (中文热线)告知我们，我们的热线服务人  
员会记录您的就诊信息，并在 2 个工作日内提供预授权号，治疗结束后我们将按发生的合理医疗费用  
在福利范围内进行赔付。  
Pre-authorization is required before certain medical procedures or treatments are  
undertaken. It is a process by which a member obtains approval for certain medical  
procedures or treatment, from Ping An Health prior to the commencement of proposed  
medical treatment. The application must be received by Ping An Health a minimum of 2  
business days prior to the scheduled treatment date.  
被保险人在进行下述第（1）至（6）项治疗前若未获得事先授权或紧急情况下未能在规定时间内  
通知本公司的，对于被保险人发生的合理且必要的医疗费用，本公司将按合同约定的赔偿范围、免赔  
额、给付比例及费用限额计算得出的金额，再乘以 60%的比例给付保险金（在可赔付金额的基础上再  
乘以 60%赔付）。  
Where the Insured fails to obtain pre-authorization prior to receiving the treatment  
of the below mentioned (1) to (6) items, or where the Insured fails to inform our  
Company within the stipulated time period in the event of an emergency, with regards  
to the reasonable and necessary medical expenses incurred by the Insured, we will pay  
reimbursement equal to the amount calculated based on the agreed coverage,  
compensation ratios, and expense limits and then multiplied by 60%.  
Pre-authorization approval does not guarantee payment of a claim in full, as actual  
diagnosis and treatment plans might be updated finally.  
预授权项目  
1
.
所有住院治疗和手术治疗（包括住院手术和门诊手术）；  
All inpatient treatments and surgeries(including inpatient and outpatient surgeries);  
单价在 5,000 元以上的检查；  
2.  
Any medical examination and laboratory test fees with unit price RMB5,000 or above;  
购买或租用胰岛素泵及其配套器械；  
3.  
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Purchase or rental of insulin pumps and ancillary equipment;  
4.  
5.  
6.  
首次特殊门诊治疗；  
First-time special outpatient treatment;  
使用白蛋白；  
Albumin use  
不符合上述条件但保险期间内预期累计医疗费用超过人民币 30,000 元的任何治疗；  
Any treatment that does not comply with the above-mentioned conditions, but is  
expected to generate accumulated medical expenses of more than RMB 30,000 within  
the insurance term.  
如何申请预授权 How to Pre-authorize  
您可以直接拨打平安健康险 24 小时服务热线+400-8833-663 转 1.  
Under the condition of certain service is required by member, the insured shall submit  
Pre-authorization request 2 days in advance, through calling 24h*7 service center:  
+86-400-8833-663*2(English service)  
根据接线员的提示，提供一些基本信息，如您的证件号码、姓名、就医需求、预计医疗费用支出  
等。Basic information of identity and condition related to certain service (such as diagnosis)  
may be required.  
平安健康险将在 1 个工作日内给予回复确认。如预授权通过，平安健康险将以短信或传真等方式  
通知到您。  
Ping An Health will contact the insured within 1 business day. Written approval will be  
sent to member by e-mail or fax if such application has been approved.  
紧急情况下，如被保险人未能及时获得预授权的，被保险人需在开始接受上述医疗项目后 48 小  
时之内通知本公司。  
In the event of an emergency, if the Insured fails to obtain pre-authorization in time,  
he/she must inform our Company within 48 hours of receiving the above-mentioned medical  
services.  
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2
、特定医院 Specified hospital  
注意：以下医院不在您的保障范围内，最新网络医院及特定医院以网站信息为准。  
Note：These following hospitals are not covered by your plan.  
The latest Specified hospitals list to web information shall prevail.  
中文网页 http://health.pingan.com/kehufuwu/yiliaowangluochaxun.shtml  
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English Site http://health.pingan.com/en/kehufuwu/yiliaowangluochaxun.shtml  
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城市 City  
医院 Provider  
医院地址 Address  
北京国际医疗中心  
北京  
北京市朝阳区亮马桥路 50 号北京燕沙中心办公楼 S111  
Beijing International Medical  
Center  
Beijing  
S111 Lufthansa Center, 50 Liangmaqiao Road, Chaoyang District  
北京  
北京天坛普华医院  
北京市天坛南里 12 号  
Beijing  
Beijing St. Michael hospital  
北京普华国际门诊部  
No.12 TianTan _Nanli Beijing  
北京  
北京市朝阳区武胜北路 54 号  
Beijing St. Michael International  
Clinic  
Beijing  
54 N. Wusheng Road, Chaoyang District  
北京和睦家医院  
北京  
北京朝阳区将台路 2 号  
Beijing United Family Hospital and  
Clinics  
Beijing  
2 Jiangtai Road, Chaoyang District  
北京和睦家建国门保健中心  
Beijing United Family Health &  
Wellness Center - Jianguomen  
北京朝阳区建国门外大街 21 号北京国际俱乐部饭店公寓楼地下一层  
B1/F, 21 Jianguomenwai Avenue,  
北京  
Beijing  
The St. Regis Residence, St. Regis Hotel Beijing  
北京市朝阳区东方东路 19 号 1 号楼会所 27 号  
No.16,The Grand Summit Beijing, Section B,Liangmaqiao  
Diplomatic Residence Compound , No.19Dongfangdong Road  
Beijing,  
北京  
北京和睦家亮马诊所  
Beijing  
United Family Liangma Clinic  
北京和睦家顺义诊所  
Beijing United Family Clinic -  
Shunyi  
北京  
北京顺义天竺开发区荣祥广场 818 号  
Beijing  
Pinnacle Plaza, Unit #818, Tian Zhu Real Estate Zone, Shunyi  
北京朝阳区三里屯西五街 5 号北信京谊大厦 C 座  
Suite 105, Wing 1, Kunsha Building No 16 Xinyuanli,Chaoyang  
District,Beijing  
北京  
国际 SOS 北京诊所  
Beijing  
Beijing International SOS Clinic  
北京朝阳区朝外大街甲 6 号万通中心 1 层  
北京  
北京百汇诊所  
1F-2F, Vantone Center No.Jia 6, Chaowai Street, Chao Yang Street,  
Beijing  
ParkwayHealth Beijing Clinic  
Beijing  
北京  
北京明德医院  
北京市朝阳区酒仙桥北路 9 号  
Beijing  
OASIS INTERNATIONAL HOSPITAL No. 9 Jiuxianqiao Bei Lu Chaoyang District, Beijing 100015 China  
上海戴是凯医学康复门诊部-portman  
上海南京西路 1376 号西楼 601 室  
分店 Sinounited Health (Shanghai  
Suite 601,Shanghai Centre,1376 West Nanjing Road  
Center)  
上海  
Shanghai  
上海  
上海戴是凯医学康复门诊部-金桥分店  
Sinounited Health(Jinqiao)  
上海天坛普华医院  
红枫路 300 弄 16 号  
Shanghai  
上海  
No.16,Lane 300 Hongfeng Rd.Pudong,Shanghai  
上海长宁区红宝石路 388 号  
Shanghai  
Shanghai St. Michael Hospital  
上海东方国际医院  
388 Hongbaoshi Road, Changning District  
上海市浦东南路 551 号(东方医院门诊大楼后门)1 楼/12 楼  
1/F&12/F, 551 South Pudong Road. Pudong District, Shanghai  
(North door of Shanghai East Hospital Outpatient Building)  
上海市虹许路 788 号 30 座底楼  
上海  
Shanghai East International  
Medical Center  
Shanghai  
上海  
百汇瑞虹医疗中心 Manderine City  
Medical Center  
Shanghai  
G/F, No. 30, Lane 788, HongXu Road  
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百汇华鹰医疗中心 Tomorrow  
Square International Medical &  
Surgical Center  
上海  
上海南京西路 389 号明天广场 4 楼  
Shanghai  
4/F, Tomorrow Square, 389 West Nanjing Road  
上海  
百汇新瑞医疗中心 Parkway  
Specialty and Inpatient Center  
百汇瑞祥医疗中心 Parkway Hong  
Qiao Medical Center  
上海市淡水路 170 号 2/3 楼  
2-3/F, 170 Danshui Road  
Shanghai  
上海  
上海市虹桥路 2258 号  
Shanghai  
上海  
2258 Hongqiao Road  
百汇瑞浦医疗中心 Parkway Jinqiao  
Medical and Dental Center  
百汇瑞新医疗中心 Parkway  
Shanghai Centre Medical & Dental  
Centers  
上海浦东新区金桥红枫路 51 号  
51 Hongfeng Road, Jinqiao, Pudong District  
Shanghai  
上海  
上海南京西路 1376 号商城西峰店 203/204 室  
Shanghai  
203-4 West Retail Plaza, 1376 West Nanjing Road  
上海  
百汇金浦医疗中心 ParkwayHealth  
Jin Mao Tower Medical Center  
上海市闵行区和美家诊所  
Shanghai United Family Clinics -  
Minhang  
上海浦东世纪大道 88 号金茂大厦裙房金茂时尚生活中心一层  
J-LIFE, Podium Building, 88 Century Avenue, Pudong New Area  
上海市闵行区华漕镇金丰路 555 弄上海网球俱乐部内  
Shanghai  
上海  
Shanghai Racquet Club, Ground Floor Clubhouse, Lane 555,  
Jinfeng Lu Huacao Town, Minhang District, Shanghai  
Shanghai  
上海和睦家医院  
上海  
上海市长宁区仙霞路 1139 号  
Shanghai United Family Hospital  
and Clinics  
Shanghai  
1139 Xianxia Road, Changning District, Shanghai  
上海华山医院东院（上海国际医院）  
A/B/C 区  
上海  
金桥红枫路 525 号 1 楼 A/B 区  
Shanghai International Hospital  
Shanghai  
Area A/B, 1/F, 525 Hongfeng Road  
(Huashan Worldwide Medical  
Center, Pudong Branch)  
上海沃德医疗中心  
上海  
上海市世纪大道 777 号 C 座  
Shanghai WorldPath Clinic  
International  
Shanghai  
Suite C, 777 Century Avenue, Shanghai  
上海  
上海臻景医疗  
上海市兴国路 78 号兴国宾馆 5 号楼  
Shanghai  
广州  
Optimum Health Care  
广州和睦家诊所  
Bd 5, Radisson Plaza Xing Guo Hotel, 78 Xingguo Road, Shanghai  
广州大道中 301 号人保大厦附楼首层  
1/F, Annex Building, PICC  
Guangzhou  
Guagnzhou United Family Clinic  
广州加美医疗中心  
Buidling, 301 Guangzhou Ave Middle  
广州  
广州市环市东路 368 号花园酒店花园大厦 5 楼  
Guangzhou CanAm International  
Medical Center  
Guangzhou  
5/F Garden Tower, Garden Hotel 368 Huanshi Dong Lu  
西部外科研究所  
广州  
广州海珠区同福中路 396 号  
Institute for Western Surgery  
China  
Guangzhou  
396 Middle Tongfu Road, Haizhu District, Guangzhou  
成都  
百汇成都医疗中心  
万象北路 18 号成都市第一人民医院内 Chengdu No. 1 People's  
Hospital, 18 Wan Xiang North Road  
Chengdu  
Parkway Chengdu Medical Center  
江苏省南京市中山东路 319 号维景国际大酒店 1 层  
Grand Metro Park Hotel, 319 East Zhongshan Road,1st  
Floor,Nanjing  
南京  
国际 SOS 南京诊所  
Nanjing  
Nanjing International SOS Clinic  
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天津河西区紫金山路喜来登饭店  
F Sheraton Hotel Apartment Building, Zi Ji Shan Road,He Xi  
天津  
国际 SOS 天津诊所  
1
Tianjin  
Tianjin International SOS Clinic  
District,Tianjin  
天津和睦家医院  
天津  
天津市河西区潭江道天潇园 22 号  
Tianjin United Family Hospital and  
Clinics (TJU)  
Tianjin  
22 Tanjiang Road, Hexi District, Tianjin  
深圳蛇口南海大道南 9 号招商国旅大厦 1 楼  
深圳  
国际 SOS 蛇口诊所  
Ground Floor, CMIT Building No.9 Nanhai Road South,Shekou,  
Shenzhen  
Shenzhen  
Shekou International SOS Clinic  
深圳  
深圳加美医疗中心  
深圳市南山区蛇口南海大道 1033 号泰格国际公寓 E0119  
E0119, 1033 Nanhai Avenue, Shekou, Nanshan District, Shenzhen  
Shenzhen  
Shenzhen CanAm Medical Center  
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保障方案 Benefit Plan  
该部分包含保障计划的明细表格。  
This section contains your Table of Benefits notes. Before you look at these, there are few  
principles to follow.  
另外，您在医院就诊时所接受的医疗服务，应该满足下列条件，才在我们的保障范围之内。  
For us to cover any treatment that you receive, it must satisfy all of the following criterions:  
治疗需与被广泛认可的医疗实践一致  
It is at least consistent with generally accepted standards of medical practice.  
治疗的种类、长度和频率需要符合医学标准  
It is clinically appropriate in terms of type, duration, location and frequency  
在下面列出的健康福利条款范围之内  
It is covered under the following terms and conditions of the plan  
货币单位：人民币元  
Currency : CNY  
计划  
主被保险人  
配偶  
子女  
Plan  
Employee  
Suppose  
Children  
人身保险  
Life Insurance  
意外伤害（身故、残疾）  
3
00,000  
一） 意外身故保险金  
Accidental death  
100,000  
100,000  
AD&D  
（
被保险人因遭受意外事故，并自事故发生之日起 180 日内因该事故身故的，本公司按其意外伤害保险金额  
给付意外身故保险金，对该被保险人的保险责任终止。  
If the insured sustains death caused solely by an accident within 180 days from the date of such  
accident, the insurer will pay the sum assured as “accidental death benefit” and the contract  
ceases to be liable for such insured.  
责任简述：  
（二） 意外残疾保险金  
Description:  
Accidental disability  
被保险人因遭受意外事故，并自事故发生之日起 180 日内因该事故造成本合同所附“残疾程度与给付比例  
表”所列残疾之一的，本公司按该表所列比例乘以其意外伤害保险金额给付意外残疾保险金。如治疗仍未结  
束的，按事故发生之日起第 180 日的身体情况进行残疾鉴定，并据此给付意外残疾保险金。  
If the insured sustains any disability caused by an accident and within 180 days from the date of  
such accident, the insurer will pay a percentage of the sum assured subject to the Indemnities’  
Schedule. If the treatment is not over, a disability appraisal will be conducted based on the  
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physical status on the 180th day and the disability benefit will be paid accordingly.  
意外险提供全球 24 小时意外保障。  
AD&D for 24hours world wide coverage  
医疗保险  
Health Insurance  
保障区域范围  
Geographic  
Coverage Area  
年度总限额  
中国大陆  
China Mainland  
Annual  
300,000  
300,000  
300,000  
Maximum  
Aggregate Limit  
被保险人因遭受意外伤害事故或疾病，经医生确诊必须住院治疗的，本公司就其每次住院发生的下列合理且  
必要的住院医疗费用，按约定给付比例在各项费用的年限额、每日限额和最高给付日数范围内给付住院医疗  
保险金：  
1.住院医疗  
If the Insured has to be hospitalized due to illness or accidental injury based on diagnosis by a  
hospital, our Company will pay the following reasonable and necessary inpatient medical  
expenses at a benefit ratio subject to the annual limits, daily limits and maximum days of coverage  
for the relevant expenses.  
Inpatient Benefits  
赔付比例  
Reimbursement  
Rate  
100%  
80%  
50%  
床位费，膳食费，护理  
费（最多 180 天/年）  
Room,  
Board,  
180  
1200/Day  
1200/Day  
1200/Day  
Nursing(max  
days/year  
床位费：住院期间实际发生的、不高于标准单人病房（或私人病房）的住院床位费（不包括套房、家庭病床）。  
Bed fees: bed fees no higher than those of a standard single ward (or private ward) incurred by  
the Insured during hospitalization (excluding suites and family wards).  
膳食费：住院期间实际发生的、由医院提供的合理的、符合惯常标准的膳食费用，但不包括住院期间购买的  
个人用品。  
责任简述：  
Description:  
Food expenses: expenses incurred by the Insured during hospitalization on standard daily meals  
provided by the hospital itself (excluding consumables bought by the Insured during the  
hospitalization period)  
护理费：住院期间根据医嘱所示的护理等级确定的护理费用。  
Nursing fees: Nursing fees of a standard determined by a doctor during hospitalization  
检查检验费，治疗费  
Examination  
Laboratory  
and  
100,000/year  
100,000/year  
100,000/year  
tests,  
other  
In-patient  
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平安健康保险股份有限公司 Ping An Health Insurance Co., Ltd.  
Treatment  
检查检验费：住院期间实际发生的、以诊断疾病为目的，采取必要的医学手段进行检查及检验而发生的合理  
的医疗费用，包括诊查费、妇检费、X 光费、心电图费、B 超费、脑电图费、内窥镜费、肺功能仪费、分子  
生化检查费和血、尿、便常规检查费等。  
Examination and laboratory test expenses: reasonable and necessary medical expenses of all  
examinations and tests performed during the inpatient treatment of the Insured for the purpose  
of disease diagnosis, including: examination, gynecological inspection, X-ray, electrocardiogram,  
type-B ultrasonic, electroencephalogram, endoscope, pulmonary function device, molecular and  
biochemical examination, routine blood, routine urine and routine stool test expenses etc.  
治疗费：住院期间以治疗疾病为目的，提供必要的医学手段而发生的合理的治疗者的技术劳务费和医疗器械  
使用费，以及消耗品的费用，包括放射疗法费、化学疗法费、注射费、机疗费、理疗费、输血费、输氧费、  
体外反搏费等。  
责任简述：  
Description:  
Treatment fees: reasonable and necessary technical service fees as charged by therapists, and  
medical equipment and consumable expenses incurred by the Insured during hospitalization  
according to his/her medical needs and or disease treatment. Treatment fees refer to: radiation  
therapy, chemotherapy, injection, mechanical therapy, physiotherapy, blood transfusion, oxygen  
transfusion and external counter pulsation expenses amongst others.  
医生费  
100,000/year  
100,000/year  
100,000/year  
Doctor fees  
责任简述：  
Description:  
药品费  
医生费：包括外科医生、麻醉师、内科医生、专科医生的费用。  
Doctor fees: including fees charged by surgeons, anesthetists, physicians and specialists.  
Drug/medication  
expenses  
100,000/year  
100,000/year  
100,000/year  
药品费：住院期间实际发生的合理且必要的由医生开具的具有国家药品监督管理部门核发的药品批准文号或  
者进口药品注册证书、医药产品注册证书的国产或进口处方药品的费用。  
Drug/medication expenses: reasonable and necessary expenses of drugs/medication used by  
the Insured during inpatient treatment. Drugs/medication refer to domestic or imported  
drugs/medications prescribed by doctors that hold a valid drug/medication approval number or  
Drug Import Registration Certificate and Pharmaceutical Product Registration Certificate as issued  
by the national drug/medication regulatory authorities.  
责任简述：  
Description:  
手术费（包括非器官移  
植手术及器官移植手  
术）  
Surgery （ Includes  
Non-organ  
100,000/year  
100,000/year  
100,000/year  
Transplant Surgery  
and  
Organ  
Transplant Surgery）  
非器官移植手术费：住院期间为治疗疾病、挽救生命而施行的非器官移植手术产生的合理手术医疗费用，包  
括手术室费、恢复室费、麻醉费、手术监测费、手术辅助费、材料费、一次性用品费、术中用药费、手术设  
备费。  
责任简述：  
Description:  
Non-organ transplantation surgery fees: reasonable and necessary medical expenses of  
non-organ transplant operations performed on the Insured during hospitalization for the purpose  
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平安健康保险股份有限公司 Ping An Health Insurance Co., Ltd.  
of disease treatment or saving life. Expenses include: operation room, rehabilitation room,  
anesthetic, operation monitoring, operation assistance, material, disposable article,  
intra-operative medication and operation equipment expenses.  
器官移植手术费：住院期间出于医学必要被保险人接受肾脏、肝脏、心脏、肺以及造血干细胞移植手术产生  
的合理手术医疗费用，包括手术室费、恢复室费、麻醉费、手术监测费、手术辅助费、材料费、一次性用品  
费、术中用药费、手术设备费。  
Organ transplant surgery fees: reasonable and necessary inpatient operation expenses of  
kidney, liver, heart, lung and hematopoietic stem cell transplant operations performed on the  
Insured out of medical necessity. Expenses include: operation room, rehabilitation room,  
anesthetic, operation monitoring, operation assistance, material, disposable article,  
intra-operative medication and operation equipment expenses.  
救护车费  
同年度总限额  
同年度总限额  
同年度总限额  
Ambulance  
Up to the annual limit  
Up to the annual limit  
Up to the annual limit  
救护车费：指住院期间以抢救生命或治疗疾病为目的，根据医生建议，被保险人需医院转诊过程中的医院用  
车费用，且救护车的使用仅限于同一城市中的医疗运送。  
责任简述：  
Ambulance expenses: ambulance expenses for the inter-hospital transfer of the Insured, as  
advised by the doctor or physician, for the purpose of saving life or treating disease during  
hospitalization. The use of ambulance is restricted to referral within one city.  
Description:  
被保险人因遭受意外伤害事故或疾病，每次在医院治疗发生的下列合理且必要的门诊急诊医疗费用，本公司  
按约定给付比例，在各项费用的年限额、每次限额以及最高给付次数范围内给付门诊医疗保险金：  
If the Insured needs outpatient or outpatient emergency treatment due to illness or accidental  
2.门(急)诊医疗  
Outpatient benefits injury, we will cover the following reasonable and necessary outpatient and outpatient emergency  
treatment expenses incurred at a hospital within the annual limits, maximum visits and maximum  
payment amounts for various expenses at the agreed benefit ratio.  
赔付比例  
Reimbursement  
Rate  
90%  
80%  
50%  
年度限额  
Annual Maximum  
Aggregate Limit  
药品费  
50,000  
50,000  
50,000  
5
0,000/year  
50,000/year  
50,000/year  
Prescription Drugs  
药品费：被保险人每次门、急诊发生的，合理且必要的由医生开具的具有国家药品监督管理部门核发的药品  
批准文号或者进口药品注册证书、医药产品注册证书的国产或进口处方药品的费用。  
责任简述：  
Drug/medication expenses: reasonable and necessary expenses actually incurred by the Insured  
during outpatient or outpatient emergency treatment on domestic or imported drugs prescribed  
by doctors with the relevant drug approval number, or Drug Import Registration Certificate and  
Pharmaceutical Product Registration Certificate issued by the state drug regulatory authority.  
Description:  
挂号费/医生诊疗费，检  
查费，治疗费，门诊手  
术费  
50,000/year  
50,000/year  
50,000/year  
Consultation  
Examination  
Laboratory  
Fees,  
and  
tests,  
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平安健康保险股份有限公司 Ping An Health Insurance Co., Ltd.  
Out-patient Surgery,  
and  
other  
Out-patient  
Treatment Expenses  
医生诊疗费：指被保险人门、急诊期间发生的主诊医生或会诊医生的劳务费用，包括挂号费。  
Consultation fees: service fees of a primary doctor or an attending physician when receiving  
outpatient or outpatient emergency treatment including registration fees  
检查检验费：指门、急诊发生的以诊断疾病为目的，采取必要的医学手段进行检查及检验而发生的合理的医  
疗费用，包括诊查费、妇检费、X 光费、心电图费、B 超费、脑电图费、内窥镜费、肺功能仪费、分子生化  
检查费和血、尿、便常规检查费等。  
Examination and laboratory test fees: reasonable and necessary outpatient or outpatient  
emergency treatment fees incurred by the Insured for the purpose of diseases diagnosis.  
Examination and laboratory test fees include: examination fees, gynecological examination fees,  
X-Ray fees, electrocardiogram fees, B-mode ultrasonic examination fees, electroencephalogram  
fees, endoscopes fees, pulmonary function equipment fees, molecular biochemical examination  
fees and fees for regular blood, urine and stool examinations.  
责任简述：  
治疗费：指门、急诊发生的以治疗疾病为目的，提供必要医学手段而发生的合理的治疗者的技术劳务费和医  
疗器械使用费，以及消耗品的费用，包括放射疗法费、化学疗法费、注射费、机疗费、理疗费、输血费、输  
氧费、体外反搏费等。  
Description:  
Treatment fees: fees paid for the technical services of the medical practitioner and the use of  
medical equipment for the purpose of necessary disease treatment, as well as for consumables  
used during the outpatient or outpatient emergency treatment of the Insured. Expenses include  
radiotherapy, chemotherapy, injection, mechanical therapy, physiotherapy, blood transfusion,  
oxygen transfusion and external counter-pulsation expenses amongst others.  
门诊手术费：指门、急诊发生的合理且必要的手术医疗费用，包括外科医生费、手术室费、恢复室费、麻醉  
费、手术监测费、手术辅助费、材料费、一次性用品费、术中用药费、手术设备费。  
Outpatient surgery fees: reasonable and necessary surgery fees incurred by the Insured during  
outpatient and outpatient emergency treatment, including surgeon fees, operation room,  
recovery room, anesthetic, operation monitoring, operation assistance, material costs, disposable  
medical supplies, inter-operative medication and surgical equipment expenses.  
糖尿病治疗用品费（含  
胰岛素泵及相关用品）  
Diabetes Treatment  
50,000/year  
50,000/year  
50,000/year  
糖尿病治疗用品费：指被保险人因患有糖尿病，为治疗或控制糖尿病使用的医疗用品而产生的相关合理且必  
要的医疗费用，包括胰岛素泵及相关用品。  
责任简述：  
Diabetic supply expenses: reasonable and necessary expenses incurred by the Insured for the  
use of supplies used to treat or control diabetes. Supplies including insulin pumps and relative  
equipment.  
Description:  
物理治疗、脊柱推拿、  
顺势治疗、针灸、职业  
疗法、语音治疗（最多  
500/visit  
500/visit  
500/visit  
10  
次
/
年
）
Physiotherapy,  
Chiropractic,  
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平安健康保险股份有限公司 Ping An Health Insurance Co., Ltd.  
Homoeopathy,  
Acupuncture  
Occupational  
、
Therapy and Speech  
Therapy  
Treatment(max  
visits/pear)  
10  
物理治疗及其他特殊疗法费：指被保险人在门诊由具有相应资格的医生进行物理治疗、脊柱推拿、顺势疗法、  
针灸疗法、职业疗法、语音治疗等的相关合理且必要的费用。  
责任简述：  
Physiotherapy and other specialized therapy fees: reasonable and necessary therapy fees  
incurred by the Insured during outpatient physiotherapy, chiropractic treatment, homeopathy,  
acupuncture, occupational therapy and speech therapy provided by qualified specialists.  
Description:  
意外牙科治疗  
Accidental  
treatment  
dental  
50,000/year  
50,000/year  
50,000/year  
意外牙科治疗费：指被保险人因意外伤害事故且在事故之日起7日内，在医院牙科门、急诊治疗原本完整无  
损的、未经过任何治疗的自身牙齿的合理且必要的紧急治疗和修复的费用（不包括牙科例行检查和牙病的诊  
治）。  
责任简述：  
Accidental dental treatment expenses: reasonable and necessary dental expenses incurred by  
the Insured within seven days of accidental  
Description:  
injury, for outpatient and outpatient emergency treatment and repair of a tooth (teeth) which was  
(were) originally intact and has (have) not received any former treatment (excluding regular dental  
check-ups and dental treatments).  
同门诊年度总限额  
救护车费  
同门诊年度总限额  
同门诊年度总限额  
Ambulance  
Up to the annual limit  
Up to the annual limit  
Up to the annual limit  
救护车费：指为抢救生命由急救中心派出的救护车运送被保险人至医疗机构的费用，救护车的使用仅限于同  
一城市中的医疗运送。  
责任简述：  
Ambulance expenses: expenses for the use of an ambulance sent by a first-aid center to  
transport the Insured to a medical facility for the purpose of saving his/her life. The use of  
ambulance is limited to transport within the same city.  
Description:  
被保险人不论一次或多次到医院进行门诊肾透析、门诊恶性肿瘤电疗、化疗或放疗的，本公司就其门诊发生  
的合理且必要的医疗费用，按约定比例给付特殊门诊医疗保险金，且累计给付金额以不超过特殊门诊医疗保  
险金的最高给付金额为限。  
3.特殊门诊医疗  
Special Outpatient Regardless of the number of times the Insured undergoes outpatient renal dialysis and outpatient  
Benefits  
cancer treatment (electrotherapy, chemotherapy or radiotherapy) in a hospital, we will cover the  
reasonable and necessary special outpatient treatment expenses at the corresponding benefit  
ratios within the annual special outpatient treatment benefit limits.  
赔付比例  
Reimbursement  
Rate  
100%  
80%  
50%  
门诊肾透析、门诊恶性  
肿瘤电疗、化疗或放疗  
Out-Patient Kidney  
Dialysis and  
50,000/year  
50,000/year  
50,000/year  
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平安健康保险股份有限公司 Ping An Health Insurance Co., Ltd.  
Out-patient Cancer  
Treatment including  
Electrotherapy,  
Chemotherapy and  
Radiotherapy  
女性被保险人在妊娠期间、流产和分娩住院期间发生的下列合理且必要的医疗费用，本公司按约定给付比例  
在年限额范围内给付女性生育保险金：  
4
.女性生育  
The following reasonable and necessary medical expenses incurred by the female Insured for  
pregnancy, miscarriage and childbirth will be covered by us at the corresponding benefit ratio  
within the annual maternity benefit limits:  
Maternity benefits  
赔付比例  
Reimbursement  
Rate  
80%  
80%  
不在保障范围内  
保额  
40,000/年  
40,000/年  
不在保障范围内  
Sum assured  
1.新生婴儿出生后 14 日内护理费、免疫费和治疗费；新生婴儿护理费指住院期间根据医嘱所示的护理等级  
确定的费用。  
Newborn infant care, treatment and immunization expenses (up to 14 days following birth);  
Newborn infant care expenses refer to the care expenses of a standard determined by a doctor for  
a newborn infant during his/her hospitalization.  
2.每次妊娠期内两次 B 超检查费，对于高危或伴有并发症的妊娠，亦包括两次以上的 B 超检查费，但须医  
生提供该项检查的医学必要性证明；  
Two type-B ultrasonic examinations per pregnancy. Where the female Insured is in high risk or has  
pregnancy complications, two or more type-B ultrasonic examinations can be covered, but the  
Insured must provide a doctor’s certificate to prove the examinations are out of medical  
necessity.  
责任简述：  
Description:  
3．产前检查、产前处方补充维生素和钙剂、自然分娩、医学必要的手术分娩、流产、产后检查、孕产期并  
发症治疗费用； 每一保单年度因流产给付的女性生育保险金仅限一次。  
Pre-natal examinations, prescribed pre-natal vitamins and minerals, natural childbirth, delivery by  
caesarean section out of medical necessity, miscarriage, post-natal examination, pregnancy and  
pregnancy complications treatment expenses;  
We will only pay maternity benefits for miscarriage once per policy year.  
被保险人因患牙科疾病，每次在医院治疗发生的下列合理且必要的牙科门诊医疗费用，本公司按约定给付比  
例在年限额范围内给付牙科医疗保险金：  
5.牙科医疗保险金  
If the Insured receives dental outpatient treatment due to dental disease, we will cover the  
following reasonable and necessary outpatient dental treatment expenses. The dental care  
benefits shall be paid after subtracting the deductibles at the agreed benefit ratio within the  
annual limits:  
Dental care  
benefits  
年度分项限额  
Annual Limit  
基本牙科治疗  
Basic dental  
treatments  
2
,000  
2,000  
2,000  
80%  
80%  
80%  
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平安健康保险股份有限公司 Ping An Health Insurance Co., Ltd.  
指简单补牙(包括银汞合金或复合树脂充填)、简单拔牙、牙周治疗(包括牙周刮治及牙根平整术)  
simple dental fillings (including dental amalgams or composite resin fillings), simple tooth  
extractions and periodontal treatments (including periodontal scaling and root planting, etc).  
责任简述：  
Description:  
重大牙科治疗  
Major dental  
treatments  
80%  
80%  
80%  
指根管治疗(包括麻醉和拍片费用)、牙冠修复、桥式义齿(包括化验和麻醉费用)、智齿拔除  
root canal therapy (including anesthesia and X-ray expenses), crowns repairs, dentures (including  
laboratory and anesthetic expenses), and wisdom teeth extractions.  
责任简述：  
Description:  
6.住院津贴  
hospitalization cash  
subsidy  
100/Day  
100/Day  
100/Day  
被保险人因疾病或遭受意外伤害事故，经医院确诊必须住院治疗的，本公司按其合理住院日数乘以住院日额  
津贴给付住院日额津贴保险金。  
住院日额津贴保险金累计给付日数最多为 180 日，累计给付住院日额津贴保险金的日数达到 180 日  
时，对该被保险人该项保险责任终止。  
责任简述：  
Description:  
If the insured needs hospitalization treatment through hospital diagnosis due to Accidental  
injury or illness the insurer will pay hospitalization cash subsidy according to the actual days of  
hospitalization of the insured.  
The maximum days for benefit payment within each policy year are 180 days.  
7.特定医院赔付比例  
Specified hospitals  
Reimbursement  
Rate  
0%  
0%  
0%  
指超出该地区惯常医疗费用水平的昂贵医院。被保险人在该类医院就医时，本公司将不承担或者按一定比例  
承担保险责任范围内的医疗费用。具体特定医院由本公司另行约定。  
责任简述：  
Refer to deluxe hospitals charging above-standard medical expenses in a specific region. Should  
any Insured receive treatment in these hospitals, this Company will bear reduced insurance  
liabilities for medical expenses incurred. We will designate special hospitals.  
Description:  
提示：医疗险无等待期；因既往症而发生的医疗费用限额 30,000。  
Note：No waiting period for medical insurance；medical fees cause by pre-existing condition  
limits to 30,000 per year.  
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平安健康保险股份有限公司 Ping An Health Insurance Co., Ltd.  
就诊及理赔须知 Treatment and claim notice  
1
、指定医院 Designated hospitals  
在本保障计划范围内，除特定医院外，只要是中国大陆内（不含港澳台）合法注册的医疗机构，  
都可以作为您就医的场所。但不包括疗养院、护理院、康复中心、戒酒或戒毒中心、精神心理治疗中  
心以及无相应医护人员或设备的二级或三级医院的联合医院或联合病房。  
特定医院：指超出该地区惯常医疗费用水平的昂贵医院。（查询地址及清单请见第 6 页）  
As long as it is covered by your plan, you can get your treatment at any recognized  
hospital or clinic in Mainland China. Hospitals exclude convalescent care facilities, nursing  
homes, rehabilitation centers, alcohol or drug rehabilitation centers, psychiatric hospitals,  
hospitals without qualified medical staff or equipment, affiliated grade 2 or grade 3 hospitals  
or wards. Specified hospitals are excluded.  
Specified hospitals：Refer to deluxe hospitals charging above-standard medical  
expenses in a specific region. We will designate special hospitals. （Specified hospitals list  
and website for checking please see page 6）  
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2
、驻点医院列表 Representative Hospital List  
我们在以下医院设有平安健康险驻点服务人员，如有需要，可以为您现场提供语言服务、医疗咨  
询服务、就医协助服务、陪诊服务。  
In the flowing hospitals , Ping An Health representative can provide insured with English  
service, medical consulting, visit assistant, visit accompany service.  
北京协和医院  
Peking Union Medical College Hospital  
首都医科大学附属北京友谊  
医院  
Beijing Friendship Hospital, Capital Medical University  
China-Japan Friendship Hospital  
中日友好医院  
Huashan Worldwide Medical Center, Affiliated to Fudan  
University  
复旦大学附属华山医院国际  
医疗中心  
复旦大学附属华东医院特需  
医疗部  
Huadong Hospital, VIP Medical Cente  
No.1 People's Hospital International Medical Care Center,  
affiliated to Shanghai Jiao Tong University  
Shuguang Hospital (Pudong Branch), VIP Clinic, affiliated to  
Shanghai Shanghai University of T.C.M  
上海交通大学附属第一人民  
医院国际医疗保健中心  
上海中医药大学附属曙光医  
院浦东分院特需中心  
Shuguang Hospital (Puxi Branch), VIP Clinic, affiliated to  
Shanghai University of T.C.M  
上海中医药大学附属曙光医  
院浦西分院名中医诊疗中心  
Shanghai Sixth People's Hospital, International Medical Center,  
Affiliated to Shanghai Jiaotong University  
上海交通大学附属第六人民  
医院国际医疗部  
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3
、理赔须知  
您在医院就诊完毕后需先向医院支付费用，然后收集完整的理赔资料，快递至前程无忧服务人员，  
最后我们会向您支付保障内规定的费用，完成理赔。  
事后理赔材料及说明  
资料名称  
备注  
需填写完整，申请人签名处需您（指被保险人本人，下同）亲笔签名（若您为未成年人，需您的  
法定监护人亲笔签名）  
理赔申请书  
身份证明复印件 您的身份证明复印件（二代身份证正反面、户口本、护照等）；  
住院或金额大于  
万元的非住院 若您为中国籍未成年人的，申请理赔金额大于 1 万元，须提供您的以及您的监护人的身份证明复  
(
1
理赔案件)  
印件、以及与监护人的关系证明 (户口本、出生证等)；  
门诊资料名称  
住院资料名称  
住院病历（可根据需要）、出院小结或疾病诊断证明原件  
备注：疾病诊断证明书须加盖医院印章）  
门诊资料复印件  
（
医疗费用发票原件（显示本人姓名，并加盖医院收费章）  
医疗费用结算清单，医疗费用明细清单  
病理、血液、X 线及 CT 报告  
被保险人所能提供的与确认保险事故的性质、原因等有关的其它证明和资料  
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3
、Claim Notice  
you need to pay the hospital first and our staff will settle with you after receiving all required materials.  
Table of materials for pay and claim  
Material  
Notes  
The insurance applicant must fill out this form and sign it with his/her name. The  
insured is referred to as the “applicant” in this form. If the insured is a minor,  
his/her legal guardian's signature is required.  
Claim Application  
Form  
Copies of Identity  
Certificates  
A copy of the insured’s identity certificates (ID card, household register, passport,  
etc);  
（
inpatient  
treatment or  
outpatient  
If the insured is a minor, copies of the identity certificates of the minor and their  
legal guardian, as well as documents or certificates proving the relationship  
between them (household register; birth certificate, etc) must be provided.  
treatment costing  
more than  
10,000yuan）  
Materials for Outpatient Treatment  
Materials for Inpatient Treatment  
Original medical records for hospitalization (if  
necessary), discharge summary or diagnosis  
certificate (Note: the diagnosis should be stamped  
with the company seal).  
Copies of Outpatient Materials  
Original invoice for medical expenses(with the client name and hospital payment chop)  
Medical expense settlement list and a detailed list of medical expenses incurred  
Pathological, blood, X-ray and CT reports  
Other certificates and documents that can be provided by the insured to help confirm the nature and  
cause of the insured accident.  
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常见问题解答 FAQ  
问：如果我要变更邮箱联系方式或银行卡号怎么办？  
Q : What should I do if I want to change my email or bank account?  
答：请及时联系前程无忧服务人员，否则将无法及时联系到您。  
A : Please inform your service specialist as soon as possible. Otherwise, you may miss some important  
notification from Ping An.  
问：是否有不承担的保障内容？  
Q：Are there any exclusions in my plan?  
答：是，本计划有除外责任，详情请参见本手册保障责任描述部分。  
A : Yes. Please see the exclusions in this handbook.  
问：我（中国人/外国人）有英/中文名字，我可以用我的英/中文名字在诊所就诊吗？相关费用可以理赔吗？  
Q : I am Chinese/Foreigner, but I have a English/Chinese name. Can I use my English/Chinese name when I  
register in clinic? Can I submit claim materials with my English/Chinese name?  
答：从合法性来看，建议您用有效证件上的姓名进行就诊，理赔系统只承认有效证件上的姓名。  
A : All insured are registered in Ping An with their official name on the valid identity card. We suggest you  
register in clinic with your official name for claim.  
问：我打算去家庭医生处就诊，但是医师通常只提供就诊费收据，我能理赔吗？  
Q : I am going to visit my family doctor who is outside borders. Usually he only gives me a receipt after the  
visit. Can I reimburse without medical record?  
答：不能。病例是理赔鉴定保险责任的重要依据。建议您向医生索取含有具体主诉、诊断、治疗的病例，和一份具体  
的费用明细清单。收据上须有医生的签章。  
A : this plan only covers drugs with doctor’s prescription. Drugs buying by yourself without prescription will  
not be reimbursed.  
问：如果我要住院，应该怎么做？  
Q : What should I do if I need to be hospitalized?  
答：如果您要住院，请提前 2 个工作日致电平安热线 95511 转 7 获得预授权。紧急情况下，在接受治疗之日起的 48  
小时内致电平安热线申请预授权。否则，只能理赔金额将是正常理赔的 60%。  
A : When you are requested to be hospitalized or expected to give birth to a baby, please call Ping An hotline  
4
008833663*2 to apply pre-authorization. As for emergency, please do as soon as possible within 48 hours  
after access to treatment.  
问：我何时能收到理赔结果？  
Q : When do I receive claim settlement?  
答：我们在收到理赔材料后，将尽快为您处理。若材料完整，一般情况下，15 个工作日内结案，结案后 7 个工作日内  
发出通知或银行转账。较复杂的案件，将在 30 个工作日内结案。理赔结果会通过电子邮件发送给您。如遇特殊情况，  
我们会与您沟通。  
A : If the claim materials are complete, at most time we finish claim within 15 days. Very complicated cases  
will be finished within 30 days. We will send you claim settlement notification by email. If any questions,  
service specialist will contact you.  
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责任免除 Exclusions  
一、因下列情形之一导致被保险人身故、伤残的，本公司不承担给付保险金的责任：  
Exclusions of the accidental death & disability benefit:  
1
2
)
)
投保人对被保险人的故意杀害、故意伤害；  
Death or injury of the insured intentionally caused by the policy holder;  
被保险人故意自伤、故意犯罪、抗拒依法采取的刑事强制措施或自杀，但被保险人自杀时为无民事行为能力人的  
除外；  
Suicide or criminal compulsory measures in case of the self-inflicted injury or the insured commits crime  
intentionally or resists the arrest, excluding the suicide of the person who has no capacity of civil  
conduct;  
3
4
)
)
被保险人殴斗、醉酒，主动吸食或注射毒品；  
The insured assaults, gets drunk, takes, sucks or injects drug;  
被保险人酒后驾驶、无合法有效驾驶证驾驶，或驾驶无有效行驶证的机动车；  
The insured drives after drinking, or drives without driving license, or drives any motor vehicle without  
vehicle license;  
5
)
战争、军事冲突、暴乱或武装叛乱；  
War, military action, civil commotion, or armed rebellion;  
6
7
)
)
核爆炸、核辐射或核污染；  
Nuclear explosion, nuclear radiation or nuclear pollution.  
被保险人因妊娠（含宫外孕）、流产、分娩（含剖宫产）导致的伤害；  
The insured’s injuries caused by gravidity (including ectopic pregnancy), abortion, confinement  
(
including cesarean birth);  
被保险人因医疗事故、药物过敏或精神和行为障碍（依照世界卫生组织《疾病和有关健康问题的国际统计分类  
ICD-10）》确定）导致的伤害；  
The insured’s injuries caused by medical accident, drug allergy, spiritual or behavioural disturbance  
confirmed by ICD-10);  
8
9
)
)
（
(
被保险人未遵医嘱，私自使用药物，但按使用说明的规定使用非处方药不在此限；  
The insured takes medicines without doctor’s permission, excluding the usage of the OTC drugs in  
accord with the instruction book;  
1
1
0) 细菌或病毒感染（因意外伤害导致的伤口发生感染者除外）；  
Bacteria or virus infection (excluding wound infection caused by accidental injuries);  
1) 被保险人从事潜水、跳伞、攀岩、蹦极、驾驶滑翔机或滑翔伞、探险、摔跤、武术比赛、特技表演、赛马、赛车  
等高风险运动。  
The insured engages in sports or activities with high risks such as diving, parachuting, climbing, bungee  
jumping, glider driving, paraglider, expedition, martial arts, wrestling competitions, acrobatics, horse  
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riding, racing, etc.  
发生上述第一项情形导致被保险人身故的，本公司对该被保险人保险责任终止，并向受益人退还该被保险人的未满期  
净保险费。  
If the insured dies because of the policy holder’s intentionally behaviors toward the insured, the insurer  
ceases to be liable for the insured and refund the unearned premium to the beneficiary after deducting  
termination fees.  
发生上述其它情形导致被保险人身故的，本公司对该被保险人保险责任终止，并向投保人退还该被保险人的未满期净  
保险费。  
If the insured dies because of the other reasons, the insurer ceases to be liable for the insured and refund the  
unearned premium to the policy holder after deducting termination fees.  
二、因下列情形之一或方案中未涵盖的责任的，造成被保险人医疗费用支出的，本公司不承担给付保险金或不承担紧  
急救援费用的责任  
We will NOT bear any liability to reimburse benefits in the following situations and conditions not  
covered in this plan:  
1
)非疾病治疗类  
Non-disease Treatments  
各种美容整形项目：如皮肤色素沉着、对皮肤表面无囊肿形成或无脓肿的痤疮治疗、红斑痤疮治疗;对未表现出可  
疑细胞行为(如近期大小、形状、颜色发生改变)的良性皮肤损害(雀斑、老年斑、痣、疣等)的治疗和去除；对浅表  
静脉曲张、蜘蛛脉、除瘢痕疙瘩型外的其他瘢痕、纹身去除、皮肤变色的治疗或手术；激光美容、除皱、除眼袋、  
开双眼皮、治疗白发、秃发、脱发、植毛、脱毛、隆鼻、隆胸等费用；  
Various beauty and plastic surgeries: such as skin pigmentation treatments, acne that does not form  
cysts or abscesses on the skin, rosacea, treatment and removal of benign skin lesions (such as freckles,  
age spots , moles and warts) that do not have an abnormal appearance or do not show change in  
appearance (size, shape and color); the treatment of or operation of superficial varicose veins, spider  
veins, and scars (other than cheloid scars) , tattoo, skin discoloration treatment or surgery; beauty laser  
therapy , wrinkle removal, eye-bag removal, double eyelid surgery, white hair or grey hair treatment,  
balding treatment, alopecia treatment, hair transplants, hair removal, rhinoplasty, breast augmentations  
etc.  
各种矫形及生理缺陷的手术和检查治疗项目：如平足、鼻鼾及各种非功能性整容、矫形手术等费用  
Surgical, examination and treatment items for a variety of orthopedic and physical defects: such as flat  
foot and snoring, as well as various nonfunctional plastic surgery and orthopedic surgery costs  
各种健美治疗项目：如营养、减肥、增胖、增高等项目费用；  
Various beauty treatment items: such as nutrition, weight- loss, weight gain and height gain  
合同中未列明的各种健康体检项目各种预防保健性项目：如保健按摩、自动按摩床治疗、药物蒸气治疗、药浴、  
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体疗健身、各种疫苗预防接种、预防注射以及疾病普查等费用；  
Various health examination items not specified under this Contract  
各种医疗咨询和健康预测：如健康咨询、家庭咨询、婚姻咨询、性咨询、婚前咨询等费用；  
Various preventive healthcare items: such as health massage therapy, massaging beds, vapor therapy,  
medicated baths, fitness therapy, preventive inoculations (excluding vaccinations under this Contract)  
and general disease surveys etc.  
医疗事故鉴定、精神病鉴定、孕妇胎儿性别鉴定、各种验伤鉴定、亲子鉴定、遗传基因鉴定等费用；  
Various medical consultations and health forecasts: such as health consultations, family counseling,  
marriage counseling, sexual counseling and pre-marriage counseling  
各种医疗鉴定。  
Various medical appraisals: such as medical malpractice assessments, mental health assessments, fetal  
gender assessments for pregnant women, assessment of injuries, DNA paternity identification, genetic  
analysis and etc.  
2) 生殖治疗类  
Reproduction Treatments  
人工辅助生殖、男女节育；  
Assisted reproduction; male and female birth control  
输精管或输卵管结扎等绝育术；  
Sterilization such as vasectomy or tubal ligation  
性功能障碍治疗；  
Treatment of sexual dysfunctions  
非紧急情况下的堕胎，因心理或社会原因实施的堕胎及造成的相关并发症，以及选择性手术分娩；  
Non-emergency abortions (abortion due to psychological or social reasons or related complications)  
and selective operative childbirth.  
不育症的检查和治疗、绝育恢复手术；.  
Infertility examinations and treatments  
变性手术；  
Transsexual operations  
用于提高性功能的药物、生育/分娩前的培训、与不育或生育相关的任何活细胞冷冻贮藏、植入和再植入费用。  
Drugs to improve sexual functions, Delivery/pre-birth training, Expenses of any living cell freezing,  
storage, implantation and re-implantation related to sterility or production  
3
) 器官移植类  
Organ Transplants  
除肾脏、肝脏、心脏、肺、造血干细胞以外的器官和组织的手术移植费用；  
Expenses of transplant operations of organs and tissues other than kidney, liver, heart, lung and  
hemopoietic stem cell transplant operations  
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供体的所有检查和治疗费用；  
All expenses for examination and treatment of the supplier  
寻找、购买、运输、贮存器官源或组织源的费用；  
Expenses on looking for, purchasing, transporting and storing the organ or tissue source  
与捐献自身组织、器官相关的任何费用。  
Any expense related to the donation of the Insured’s own organs and tissues  
4
) 治疗项目类  
Treatment Items  
除心脏瓣膜、人工晶体、人工关节之外的人工器官材料费、安装和置换等费用；  
Expenses of materials, installation and replacement of artificial organs, except for cardiac valves,  
artificial lenses, joint prosthesis etc.  
被保险人患性病、艾滋病或感染艾滋病病毒期间因疾病所导致的医疗费用(保障计划已覆盖除外)；  
Treatment expenses of sexually transferred diseases, AIDS or diseases caused by the infection of HIV  
(
unless covered by your plan).  
依据具有相应资格的医生判断，无医学必要性的手术和治疗，包括近视和斜视矫形术费用；  
Expenses of operations and treatments that are deemed medically unnecessary by doctors with  
corresponding qualifications such as orthopedic surgery for short sightedness (myopia) and strabismus  
在健康水疗院、自然治疗诊所或类似疗养机构接受的治疗，或以隶属于该类机构、登记为“护理病房”的私人病  
床形式接受的治疗；  
Treatment at health spas, natural therapy clinics or similar institutions, or treatment at private sickrooms  
belonging to such institutions and registered as “care wards”  
为休息、观察而实施的环境疗法，在任何长期护理机构、矿泉疗养地、水疗院门诊、康复机构、疗养院、养老院  
等非本合同规定的医疗机构接受的服务或治疗；  
Environmental therapy for rest or observation, or services and treatments received at any long-term  
care institution, spa resort, hydrotherapy clinic, rehabilitation centre, nursing room or medical  
institution not specified under this Contract.  
包皮环切术。  
Circumcision.  
5
) 服务设施及医学材料类  
Emergency Medical Treatments  
使用电话、电炉、煤气、食品保温箱等费用；  
Telephone, electrical oven, gas and warming drawer costs  
遗体料理费、遗体冷藏费；  
Expenses of disposal or refrigeration of remains  
陪护费、陪床费(本合同约定属于保险责任范围内的除外)、护工费、洗理费及各种与诊疗无直接关系的费用（如  
脸盆、卫生塑料费、卫生纸费等）；  
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Escort and extra bed fees (except coverage specifically described in this Contract), nursing fees,  
cleaning fees and various expenses not directly associated with the diagnosis and treatment of the  
Insured (such as bathroom and sanitary expenses)  
各种康复治疗器械：如矫形器、助听器、眼镜、义眼、义肢等费用；  
Expenses of various rehabilitation devices, such as orthotic devices, hearing aids, eye-glasses (except as  
described within the coverage of this Contract), artificial/ prosthetic eyes and artificial limbs etc.  
各种自用的按摩保健和治疗用品：颈托、腰托、胃托、肾托、阴囊托、子宫托、疝气带、护膝带、钢头颈、足部  
矫正鞋、矫正器具、药带、药枕、拐杖、轮椅、健身按摩器和各种磁疗用品及家用检测治疗仪器等费用；  
Expenses of various massaging, health and treatment articles for the Insured, such as neck supports,  
abdominal belts, dinner pads, kidney pads, scrotal supports, uterus supports, hernia trusses, knee cap  
bandages, steel neck supports, orthopedic shoes and other orthopedic devices, medicated belts,  
medicated pillows, crutches, wheelchairs, health massagers, various magnetic articles and treatment  
and testing devices for home use  
定制或改造任何交通工具、洗浴设备或者住宅设备；  
Any vehicle, bathing equipment or home equipment made to order or adapted in any way  
所有非处方(OTC)医疗器械；  
All over-the-counter (OTC) medical devices  
非手术中必需的假体、矫正器具、支具或相似的器具，但医生确认此假体或耐用医疗设备为治疗过程中必不可少  
的除外。  
Non-surgical prosthesis, corrective devices, braces or similar apparatuses, except prosthesis or durable  
medical equipment that is confirmed by the doctor as indispensible in the treatment of the Insured.  
6
) 药品费用  
自购药品：自购药品指被保险人未经过医院所属的具有执业医生资格的医生开具医嘱，自行至药房、超市、医院  
所属商业药房等地点购买的药品；  
Self-purchased drug/medication expenses: refer to the medication/drug purchased by the Insured  
him/herself at a pharmacy, supermarket, or a hospital-affiliated pharmacy etc. without obtaining the  
advice of a qualified medical practitioner  
维生素、矿物质、膏方及其他营养保健药费；  
Vitamin (except vitamins prescribed within the coverage of this Contract), mineral, Chinese herbal  
medicines, paste prescription and other nutritious health medication/drug expenses  
医生开具的、超过 90 天部分的药品费用。  
Expenses of prescribed medication that exceed the 90-day treatments amounts prescribed by a doctor.  
7
) 特定医疗费用  
Specific Medical Expenses  
超出通常惯例的医疗费用；  
Medical expenses exceeding the standard price  
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为获得治疗发生的交通费，本合同列明的本地救护车费及紧急医疗运送除外；  
Transport expenses used for the purpose of receiving medical treatment, except local ambulance  
expenses and emergency medical evacuation expenses as stipulated under this Contract  
保险期间届满后发生的医疗费用，包括在此后按疗程使用的处方药品费用。  
Medical expenses incurred after the expiration of the insurance period, including prescribed  
medication/drug expenses that form a part of a course of treatment (except medical expenses  
described within the coverage of this Contract).  
9) 牙科治疗类  
Dental treatment  
不属于本合同约定保险责任范围内的牙科医疗费用，如非治疗必需的、以美容为目的的牙齿处理、美白牙齿、种  
植牙、嵌体、正畸治疗、贴面以及任何牙科治疗过程中使用的贵金属材料的相关费用；  
Dental treatment expenses that do not fall into the scope of coverage agreed in this insurance Contract.  
Dental treatments not covered by our Company include: non-essential dental treatments, cosmetic  
dental treatments, teeth whitening, dental implants, dental inlays, orthodontic treatments, dental  
veneers and precious metals used in any dental treatments.  
对于意外牙科保险责任，对曾接受过治疗或有裂缝牙齿的治疗，以及由于咀嚼食物（即使其中包含异物）引起的  
牙齿伤害的治疗。  
Insurance coverage of dental accidents, such as the treatment of fractured teeth that have undergone  
the treatment before or dental injury caused by chewing foods (even if the food contained foreign  
matter)  
10) 其他  
Miscellaneous  
被保险人所患既往症及保险单中特别约定的除外疾病引起的医疗费用；  
Medical expenses for pre-existing conditions and diseases specifically excluded in this Contract  
被保险人殴斗、醉酒，主动吸食或注射毒品导致的医疗费用；  
Medical expenses for the treatment of medical conditions resulting from fighting, drunkenness or  
deliberate use of illegal drugs by the Insured.  
投保人对被保险人的故意杀害、故意伤害；  
Should the policyholder injure or kill the Insured on purpose  
被保险人故意自伤、故意犯罪或者抗拒依法采取的刑事强制措施导致的医疗费用；  
Medical expenses arising from the intentional self-inflicted injury, intentional crime or resistance  
against the criminal coercive measures taken according to the law by the Insured.  
被保险人参加或从事潜水、跳伞、攀岩运动、蹦极、驾驶滑翔机、探险活动、武术比赛、摔跤比赛、特技表演、  
赛马、赛车等高风险运动导致的伤害引起的治疗；  
Treatment arising from injuries caused by the Insured’s participation or involvement in diving,  
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skydiving , rock climbing, bungee jumping, paragliding, adventure sports, martial art competitions,  
wrestling, special effect performances (stunts), horse racing, car racing or other high-risk sports  
被保险人先天性畸形、先天性疾病、遗传性疾病、染色体异常(以世界卫生组织颁布的《疾病和有关健康问题的国  
际统计分类(ICD-10)》为准)引起的医疗费用；  
Medical expenses incurred by the Insured on account of the treatment of congenital malformation or  
disease, genetic disease or chromosome abnormalities (determined in line with the International  
Statistical Classification of Diseases and Related Health Problems (ICD-10) of the World Health  
Organization)  
由于职业病、医疗事故引起的医疗费用；  
Medical expenses incurred due to occupational diseases and medical malpractice  
被保险人酒后驾驶、无合法有效驾驶证照驾驶或驾驶无合法有效行驶证的机动交通工具导致交通意外引起的医疗  
费用；  
Medical expenses arising from a traffic accident caused by the Insured who drove after drinking, and  
had no legal and valid driving license or drove a motor vehicle without a valid driving permit  
核爆炸、核辐射或核污染、化学污染；战争、军事行动、暴乱或武装叛乱；  
Nuclear explosions, nuclear radiation, nuclear contamination, chemical contamination, wars, military  
conflicts, riots or armed rebellions  
冒名住院、不符合入院标准、挂床住院或住院病人应当出院而拒不出院(从医院确定出院之日起发生的一切医疗费  
用)；  
False hospitalization, noncompliance with hospital admission criteria, refusal to accept hospital  
discharge (medical expenses incurred during hospitalization as determined by the hospital)  
被保险人接受实验性治疗，即未经科学或医学认可的医疗。  
Should the Insured undergo experimental treatment, namely medical treatment not recognized by  
science or medicine.  
三、因下列情形之一，造成被保险人住院治疗的，本公司不承担给付住院津贴保险金的责任：  
1
)
投保人对被保险人的故意杀害、故意伤害；  
Death or injury of the insured intentionally caused by the policy holder;  
2
)
被保险人患先天性疾病、遗传性疾病、精神和行为障碍、先天性畸形、变形或染色体异常（依照世界卫生组织《疾  
病和有关健康问题的国际统计分类》（ICD-10）确定）；  
Medical expenses incurred by the Insured on account of the treatment of congenital malformation or  
disease, genetic disease or chromosome abnormalities (determined in line with the International  
Statistical Classification of Diseases and Related Health Problems (ICD-10) of the World Health  
Organization)  
3
)
被保险人不孕不育治疗、人工受精、怀孕、分娩（含难产）、流产、堕胎、节育（含绝育）、产前产后检查以及  
由以上原因引起的并发症，但因意外伤害事故所致的分娩（含难产）、流产及其并发症，不受此限；  
The insured’s injuries caused by Infertility, gravidity(including ectopic pregnancy), abortion,  
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confinement (including cesarean birth);Pre-natal examinations, natural childbirth, delivery by caesarean  
section out of medical necessity, miscarriage, post-natal examination, pregnancy and pregnancy  
complications treatment Assisted reproduction; male and female birth control.  
(
Birth or abortion by accident are not excluded )  
4
5
)
)
被保险人接受矫形、视力矫正手术、美容、牙科保健及康复治疗、非意外伤害事故所致的整容手术；  
Surgical, examination and treatment items for a variety of orthopedic and physical defects: such as flat  
foot and snoring, as well as various nonfunctional plastic surgery and orthopedic surgery costs  
被保险人健康检查、疗养、静养或特别护理；  
Environmental therapy for rest or observation, or services and treatments received at any long-term  
care institution, spa resort, hydrotherapy clinic, rehabilitation center, nursing room or medical  
institution not specified under this Contract.  
6
)
被保险人从事潜水、跳伞、攀岩、蹦极、驾驶滑翔机或滑翔伞、探险、武术比赛、摔跤、特技表演、赛马、赛车  
等高风险运动；  
Treatment arising from injuries caused by the Insured’s participation or involvement in diving,  
skydiving , rock climbing, bungee jumping, paragliding, adventure sports, martial art competitions,  
wrestling, special effect performances (stunts), horse racing, car racing or other high-risk sports  
被保险人患未告知的既往症及保险单中特别约定的除外疾病；  
7
8
)
)
Medical expenses for pre-existing conditions and diseases specifically excluded in this Contract  
被保险人故意自伤、故意犯罪或抗拒依法采取的刑事强制措施；  
Medical expenses arising from the intentional self-inflicted injury, intentional crime or resistance against  
the criminal coercive measures taken according to the law by the Insured.  
被保险人殴斗、醉酒，主动吸食或注射毒品；  
9
)
Medical expenses for the treatment of medical conditions resulting from fighting, drunkenness or  
deliberate use of illegal drugs by the Insured.  
1
1
0) 被保险人未遵医嘱，私自使用药物，但按使用说明的规定使用非处方药不在此限；  
The insured takes medicines without doctor’s permission, excluding the usage of the OTC drugs in  
accord with the instruction book;  
1) 被保险人酒后驾驶、无合法有效驾驶证驾驶或驾驶无有效行驶证的机动车；  
Medical expenses arising from a traffic accident caused by the Insured who drove after drinking, and  
had no legal and valid driving license or drove a motor vehicle without a valid driving permit  
2) 被保险人患性病、艾滋病或感染艾滋病病毒期间因疾病导致的医疗费用；  
1
1
Treatment expenses of sexually transferred diseases, AIDS or diseases caused by the infection of HIV  
3) 战争、军事冲突、暴乱、武装叛乱、化学污染或恐怖行为；  
Chemical contamination, wars, military conflicts, riots or armed rebellions  
1
4) 核爆炸、核辐射或核污染。  
Nuclear explosions, nuclear radiation, nuclear contamination  
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伤残程度与给付比例表 Disability level& reimbursement schedule  
本合同约定的伤残评定标标准：《人身保险伤残评定标准》,详见下页条款 20-35 页  
伤残等级  
赔付比例  
Disability level  
Reimbursement Rate  
按《人身保险伤残评定标准》  
1
2
3
4
5
6
7
8
9
1
级
级
级
级
级
级
级
级
级
0级  
100%  
90%  
80%  
70%  
60%  
50%  
40%  
30%  
20%  
10%  
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平安健康高端医疗险员工手册签收单  
本人  
于
年
月 日收到平安健康保险股份有限公司上海分公司《员工手册》一  
份（31 页），已知悉员工手册之内容，如果由于本人原因造成商保无法正常理赔的相关费用及后果，  
由本人自行负担。特此签收。  
签字：  
签定日期：  
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