FLEXI CHOICE GROUP INSURANCE PLAN

Number of employees

• The company must have 3 to 100 full-time employees.
  

Age of employees

• Full-time employees: age 64 or below
  
• Employees between the ages of 65 and 69 are allowed to renew their existing policies, but not to enrol for the first time.
  

Age of employees’ dependants

• Spouse: age 64 or below
  
• Spouses between the ages of 65 and 69 are allowed to renew their existing policies, but not to enrol for the first time.
  
• Unmarried dependant children: from the age of 2 weeks to 18 years; full-time students are eligible up to the age of 22 (proof of full-time education is required).
  

This plan is not applicable to the below industries / organisations:

1. Group where other than a single employer or employee relationship exists
2. Group where eligible employees include seasonal, unskilled, part-time or transient workers
3. Association of individuals or companies
4. Bus, taxi or truck driver (Risks involved with driving in mainland China will be excluded)
5. Construction group
6. Labour union
7. Hospital / doctor / nurse / medical or clinic group
8. Political or religious group
9. Sports team
10. Underground mine worker
11. Farmer / agriculture / animal processing
12. Employee leasing firm or temporary agency
13. Window and/or industrial cleaning service
14. Spa, Turkish bath, massage parlor, gymnasium, health resort or similar enterprises
15. Theatre, amusement park, dance hall, billiard parlor, and bowling alley or sports promoter
16. Group which involves special hazards / risks
    • Commercial airline personnel
    • Nuclear power or chemical production plant
    • Police or security officer
    • Fireman
    • Manufacturer or user of ammunition or explosive
    • Military and military related group
    • Collective traveling group (e.g. Professional sports team, air crew, offshore worker, oil rig worker, ship crew, diver or driller (oil, water, underground coal), underground miner)

1. You need to pay the premium for this plan upon renewal every year.
   
2. The insured member will lose the cover when the following happens:
   
   • the insured member passes away.
3. We will terminate your policy and all the insured members will lose their cover when one of the following happens:
   
   • you do not pay the premium within 31 days of the premium due date;
     
   • the number of insured full-time employees falls below 3;
     
   • the nature of the company’s business changes to another nature that we shall cease to provide cover. For the latest list of the excluded industries / organisations, please refer to the section of “Excluded industry/organisation”; or
     
   • the company provides incorrect information or is unable to disclose important information regarding the insured members.
4. The insured member may lose the cover when he or she no longer resides in Hong Kong.
   
5. We reserve the right to terminate your policy and all the insured members will lose their cover when the company transfers to operate out of Hong Kong.
   
6. Cover renewal is based on the continuing availability of the plan to all existing policies.
   
7. We underwrite the plan and you are subject to our credit risk. If we are unable to satisfy the financial obligations of the policy, the insured members may lose their cover and you may lose the remaining premium and levy for that policy year.
   
8. The future medical costs will be higher than they are today due to inflation. Hence, the benefit amounts and the future premium rate of this plan may be revised to reflect the inflation.
   
9. Your current planned benefit may not be sufficient to meet the future needs of the insured members since the future cost of living may become higher than they are today due to inflation. Where the actual rate of inflation is higher than expected, the insured members may receive less in real terms even if we meet all of our contractual obligations.
   

Under this plan, we will not cover conditions that result from any of the following events:

All benefits exclusion

Any claim directly or indirectly, wholly or partly caused by AIDS or HIV.

Life benefit exclusions

1. If the death was caused, directly or indirectly, wholly or partly, by a pre-existing condition for which the insured employee showed symptoms or received medical treatment, diagnosis, consultation or prescribed drugs during the 12 months preceding the effective date of the cover, unless the insured employee affected by such pre-existing condition has been insured under this policy continuously for 12 months.
   
2. In case of suicide, whether while sane or insane, within 1 year from the effective date of the cover, we will only offer a refund limited to the total premiums paid for life insurance benefit for the insured employee. This also applies to any subsequent increase in life insurance benefit that comes into effect within 1 year.

Accident benefit exclusions

1. Suicide, self-inflicted injuries or any attempt thereat, while sane or insane. 
2. War, declared or undeclared, revolution or any warlike operations. 
3. Riot and civil commotion, strikes or terrorist activities. 
4. Violation or attempted violation of the law or resistance to arrest. 
5. Entering, operating or servicing, riding in or on, ascending or descending from or with any aerial device, or conveyance except while the insured employee is a fare-paying passenger in an aircraft operated by a commercial passenger airline on a regular scheduled passenger trip over its established passenger route. 
6. Racing on horse or wheels.
   

Medical benefits exclusions

Medical benefits include hospitalisation and surgical benefits, other benefits, increased overseas hospitalisation benefit (due to accident), extended benefits, supplementary major medical benefits, optional outpatient benefits and optional dental benefits.

1. Pre-existing conditions for which the insured member showed symptoms or received medical treatment, diagnosis, consultation or prescribed drugs within the 12 months preceding the effective date of the cover, unless the insured member has been insured under the policy continuously for 12 months. 
2. Investigation and treatment of psychological, emotional, mental or behavioural conditions; alcoholism or drug addiction; rest cure or sanitaria care; treatment of an optional nature; intentionally self-inflicted Injuries while sane or insane. 
3. Injuries arising directly or indirectly from war, declared or undeclared. 
4. General physical or medical check-up or tests not incidental to treatment or diagnosis of an actual Sickness or Injury or any treatment which is not medically necessary; immunisation, vaccination or inoculation.
5. Procurement or use of special braces, any appliances, any equipment or prosthetic devices, any implants, contact lenses, eye glasses, hearing aids or the fitting of the same and non-medical services such as television, telephone and the like. 
6. Any dental (except where and as covered under optional benefit) or eye examination/treatment, surgical procedure for correction of eye refraction, cosmetic procedures or plastic surgery except to the extent that such surgery is necessary for the repair of damage caused solely by accidental bodily injuries covered under the policy. 
7. Any investigation, treatment or surgery for congenital defect that gives rise to signs or symptoms, or is diagnosed, before the insured member reaches the age of 17. 
8. Birth control measures, investigation or treatment pertaining to infertility, genetic testing or counselling, treatment occasioned by or resulting from pregnancy, childbirth or abortion.
9. Non-medically necessary health services inclusive of treatment, investigation, supplies and admission.
10. Experimental, investigational or unproven services except when authorised by the Company.
11. Services and supplies for smoking cessation programmes and the treatment of nicotine addiction.
12. Services rendered by a Physician, Surgeon, or Chinese Medicine Practitioner (whether legally registered or not) with the same legal residence as the insured member or who is a member of the insured member’s family, including spouse, brother, sister, parent or child; or services delivered by an agent of the Company. 
13. Chinese Medicine Practitioner treatment, including Chinese herbal medicine, bonesetting, acupuncture and tui na (except where and as covered under optional benefit), hypnotism, massage therapy, aroma therapy, and other forms of alternative treatments.
14. Clinical home care; convalescence or custodial care in any setting; day care; hospice, private duty nursing; respite care unless prior approval is obtained from the Company. 
15. Other education services such as speech improvement, diabetic classes and nutritional services, or group support services.

Additional dental benefits exclusions

1. Dental appliances. 
2. Charges for any dental procedures which are not included in the Benefits Schedule. 
3. Treatment by any person other than a dentist.
4. Charges for dentures (except when necessitated by an accident).
5. Charges for services and supplies that are partially or wholly cosmetic in nature, including charges for personalisation or characterisation of dentures, unless the services are recommended as necessary by a dentist.
   

The above list is for reference only. Please refer to the policy contract of this plan for the complete list and details of exclusions.

1. Premium Adjustment

In order to provide you with continuous protection, we will annually review and adjust the premium of your plan accordingly at the end of policy year if necessary. During the review, we may consider factors including but not limited to the following:

• Claim costs incurred from all policies under this plan and the expected claim outgo in the coming year which reflects the impact of medical trend, medical cost inflation and product feature revisions; 
• your company size, years under this plan and the cost of your claims; 
• expenses directly related to the policy and indirect expenses allocated to this product.

2. Product Features Revision

We reserve the right to revise the benefit structure, terms and conditions and/or product features, so as to keep pace with the times for medical advancement and to provide you with continuous protection.

We will give the policyholder a written notice of any revision before any policy anniversary or upon renewal.

We only cover the charges or expenses of the insured member on reasonable and customary basis.

“Reasonable and customary” means:

• the medical services, diagnosis and / or treatments are medically necessary and delivered according to standards of good medical practice;
• the costs of the medical services and the duration of the hospital stay are not more expensive or longer than the usual level of charges or duration for similar treatment in the locality of such services delivered;
• the medical procedure or treatment during hospital stay is not routinely performed on an outpatient basis and could not reasonably be performed on the insured member as an outpatient according to standards of good medical practice; and
• does not include charges that would not have been made if no insurance existed.

“Medically necessary” means that the medical services, diagnosis and / or treatments are:

• delivered according to standards of good medical practice;
• necessary; and
• cannot be safely delivered in a lower level of medical care.

Experimental, screening, and preventive services or supplies are not considered medically necessary. We may adjust any and all benefits payable in relation to any hospital / medical charges which is not a reasonable and customary charge.

If any of the insured members wishes to make a claim, he/she must send us the appropriate form and relevant proof within 90 days of the date the covered event happened. The appropriate claim form can be downloaded from our website: aia.com.hk or obtained from the financial planner.

You have the right to cancel the policy by giving no less than 31 days’ prior written notice to us, however this will result in the insured member losing his cover and you losing the remaining premium and levy for that policy year. We also reserve the right to cancel the policy upon the policy renewal by giving you no less than 31 days’ prior written notice.