Accident
shall mean a sudden and unforeseen event occurring entirely beyond the control of the Insured Person and caused by violent, external and visible means.
Age
shall mean the age next birthday of the Insured Person of this Policy, unless otherwise specified.
Confinement or Confined
shall mean an admission of the Insured Person to a Hospital that is recommended by a Registered Medical Practitioner for Medical Service and as an Inpatient as a result of a Medically Necessary condition.
Confinement shall be evidenced by a daily room charge invoiced by the Hospital and the Insured Person must stay in the Hospital continuously for the entire period of Confinement.
Congenital Condition(s)
shall mean (a) any medical, physical or mental abnormalities existed at the time of or before birth, whether or not being manifested, diagnosed or known at birth; or (b) any neo-natal abnormalities developed within 6 months of birth.
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.
Disability
shall mean a Sickness or Disease or Injury, including any and all complications arising therefrom.
Eligible Expenses
shall mean expenses incurred for Medical Services rendered with respect to a Disability.
Medically Necessary
Medically Necessary shall mean 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.
For the purpose of these Terms and Benefits, without prejudice to the generality of the foregoing, circumstances where a Confinement is considered Medically Necessary include, but not limited to –
(i) the Insured Person is having an Emergency that requires urgent treatment in Hospital;
(ii) surgical procedures are performed under general anaesthesia;
(iii) equipment for surgical procedure is available in Hospital and procedure cannot be done on a Day Patient basis;
(iv) there is significantly severe co-morbidity of the Insured Person;
(v) taking into account the individual circumstances of the Insured Person, the attending Registered Medical Practitioner has exercised his prudent professional judgment and is of the view that for the safety of the Insured Person, the medical service should be conducted in Hospital;
(vi) in the prudent professional judgment of the attending Registered Medical Practitioner, the length of Confinement of the Insured Person is appropriate for the medical service concerned; and/or
(vii) in the case of diagnostic procedures or allied health services prescribed by a Registered Medical Practitioner, such Registered Medical Practitioner has exercised his prudent professional judgment and is of the view that for the safety of the Insured Person, such procedures or services should be conducted in Hospital.
For the purpose of exercising his prudent professional judgement in (v) to (vii) above, the attending Registered Medical Practitioner shall have regard to whether the Confinement –
(aa) is in accordance with standards of good and prudent medical practice in the locality for the medical service rendered, and, in the prudent professional judgement of the attending Registered Medical Practitioner, not rendered primarily for the convenience or the comfort of the Insured Person, his family, caretaker or the attending Registered Medical Practitioner; and
(bb) is in the setting that is most appropriate in the circumstances and in accordance with the generally accepted standards of medical practice in the locality for the medical service rendered.
Pre-existing Condition(s)
shall mean, in respect of the Insured Person, any Sickness, Disease, Injury, physical, mental or medical condition or physiological degradation, including Congenital Condition, that has existed prior to the Policy Date. An ordinary prudent person shall be reasonably aware of a Pre-existing Condition, where –
(a) it has been diagnosed;
(b) it has manifested clear and distinct signs or symptoms; or
(c) medical advice or treatment has been sought, recommended or received.
Reasonable and Customary
FWD shall only cover charges or expenses which FWD believes are Reasonable and Customary. Reasonable and Customary shall mean, in relation 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 for people with similar conditions, e.g. of the same sex and similar Age, for a similar Disability, as FWD reasonably determine in utmost good faith.
The Reasonable and Customary charges will never in any circumstance exceed the actual charges incurred. FWD may exercise the right to determine whether the charges for treatment, medical services and supplies are regarded as Reasonable and Customary with reference to treatment or service fee statistics and surveys in the insurance or medical industry; internal or industry claim statistics; gazette published by the Government; and/ or other pertinent source of reference in the locality where the treatments, services or supplies are provided.
FWD may exercise the right to adjust any benefit payable in relation to any charges which are not Reasonable and Customary.
Standard Semi-private Room
shall mean a room categorised as a semi-private room by a Hospital in Hong Kong. For Hospitals without the corresponding ward class categorisation or any Hospitals outside Hong Kong, a Standard Semi-private Room shall mean (i) a single or two-bedded room; or (ii) a room with maximum double occupancy, and with a shared bath/shower room in a Hospital. In any case mentioned above, a Standard Semi-private Room shall exclude any room of upper class with its own kitchen, dining or sitting room(s).
Standard Private Room
shall mean a room categorised as a private room by a Hospital in Hong Kong. For Hospitals without the corresponding ward class categorisation or any Hospitals outside Hong Kong, a Standard Private Room shall mean a room for Insured Person’s private use during the Confinement with its own private facilities including a bedroom and bath/shower room(s) only. In any case mentioned above, a Standard Private Room shall exclude any room of upper class with its own kitchen, dining or sitting room(s).
Standard Ward Room
shall mean a room categorised as a ward class lower than a Standard Semi-private Room including the room categorised as a general ward or standard room by a Hospital in Hong Kong. For Hospitals without the corresponding ward class categorisation or any Hospitals outside Hong Kong, a Standard Ward Room shall mean a room in a Hospital with more than 2 patient beds (not including companion bed).
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