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2019-2020 EXPLORER Medical Insurance Plan for SISB Public Company Limited (Management Plan) June 20th 2019
Commitment to a
Healthier Life
Thank you for giving us the opportunity to look after your healthcare needs. Everything we do is about making people healthier. This guide provides you with a summary of how to get the most out of your relationship with HSC. We look forward to being 1 there for you and your family. CONTENTS
Your benefits 3-6
⚫ Understand your policy benefits, limits, copayment/deductible, and major exclusions.
Contact us 7
⚫ Anytime you need assistance, our Service Ninja is always ready to help.
HSCDirect 8
⚫ Our direct billing network gives you access to world-class service and hassle-free
hospital experience.
Pre-authorization 9
⚫ Have your treatment arranged in advance for peace of mind.
Pay-and-Claim 10
⚫ Submit your claims via email for quick reimbursement.
Medical Advice 11
⚫ Sit back and relax when you need a local/travel medical advice or facility
recommendation.
Add-on services 11
⚫ More personalized services ready at hand to save your time and trouble.
This Membership Guide explains the terms and conditions of the Company Plan, instructions on direct billing, pre-authorization, filing a claim and your service manager contact details. It also explains your benefits, limits and exclusions with detailed rules on how to use them. It is a summary of benefits and services. In case of any ambiguity and for information about other matters not provided here, please refer to the terms and conditions of the insurance contract, which shall prevail.
2 Your Benefits
Policyholder: SISB Public Company Limited Policy Year: Sept 2nd 2019 – Sept 1st 2020 Per Claim Excess: Nil Optional Wellness Benefit: No Optional Group Dental Benefit: No Optional Group Vision Benefit: No Optional War and Terrorism Benefit: No Optional Maternity: No
Major exclusions:
▪ Non-disease-treatment services, including but not limited to cosmetic treatments, treatment of benign skin lesions, surgeries for superficial varicose veins, expenses for flat foot, various non-functional plastic surgeries and orthopedic surgeries, body building, preventative healthcare, medical identification, etc. ▪ Treatment related to reproduction, including but not limited to assisted reproduction, birth control, sexual dysfunction treatment, abortion (not in case of emergencies), egg freezing, etc. ▪ Treatment related to AIDS/HIV, myopia, circumcision, treatment not medically necessary, treatments in hydropathics, natural therapy clinics, sanatoriums, or not legally registered medical facilty, etc. ▪ Self-purchase medicine, OTC, prosthesis, transport expenses, expenses for mental health, non- medical expenses, expenses for multivitamins, minerals, herbal pastes, etc, expenses due to self-injury or fighting, high risk activities, medical accidents, experimental treatment, etc.
Please note that the list here is only for brief reference. The detailed exclusions are listed in your group policy. Please contact us should you have any confusion or enquiry.
3 Schedule of Benefits
Unit: THB per Insured Person per Policy Year, unless stated otherwise. Lifetime & Annual Maximums Overall Policy Year Maximum per Insured Person 1,000,000 Overall Inpatient Maximum Up to Overall Policy Year Maximum 2,500 per day Overall Outpatient Maximum 1 visit per day up to 30 visits per policy year Congenital Conditions, Birth Anomalies (subject to Overall Inpatient Maximum or Overall Outpatient Maximum) All treatment costs for Congenital Conditions or birth anomalies Not covered Chronic Conditions (subject to Overall Inpatient Maximum or Overall Outpatient Maximum) All treatment costs for Chronic Conditions Fully Covered Catastrophic Illnesses (subject to Overall Inpatient Maximum or Overall Outpatient Maximum) Catastrophic Illnesses, as defined in the Policy Fully Covered Hospitalization and Inpatient Benefits (subject to Overall Inpatient Maximum) Daily Room Fee 6,000 per day Meals Included in Room & Board Fee Companion Bed (see Policy for age limits) Not covered Intensive Care, Cardiac Units 12,000 per day Nursing Care Included in Room & Board Fee Medical treatment, drugs, medications, laboratory, x-rays, diagnostic procedures and tests, biological anesthesia and oxygen services, blood products and their administration, dressings Radiation therapy, inhalation therapy, respiratory therapy, chemotherapy, physical and occupational therapy 120,000 per disability Video Laryngoscope Operating room and recovery room Day-care Treatment As per Hospitalization and Inpatient benefits, received as a Day-care patient. Inpatient Consultation by a Physician or Specialist Surgery 6,000; Non-surgery 5,000 Doctor’s visit 3,000 per day Inpatient Surgery Inpatient Surgeon& any Assistant Surgeon 100,000 per disability Anesthesiologist & any secondary assistants Ambulance Services 5,000 per disability Emergency Room (if leads to Hospital Admission) 10,000 per disability Extended Care Facility, Skilled Nursing, inpatient Rehabilitation Must be confined to facility immediately following or in lieu of a Hospital stay Not Covered Transplant Services Medically Necessary human organ, blood, bone marrow, stem cell transplants, and other similar procedures. Expenses for Donor, Donor Not Covered search, and transplant tissue fees are not covered.
4 Durable Medical Equipment Not Covered Purchase, Rental Up to Purchase Price (as described in the Policy); Repairs or replacements for Durable Medical Equipment originally obtained under this Policy. Outpatient Benefits (subject to Overall Outpatient Maximum) Outpatient Physician Visit/Consultation by Specialist Outpatient Prescription Drugs Outpatient Surgeon& Assistant Surgeon Outpatient Anesthesiologist & any secondary assistants Echocardiography, Ultrasound, CAT Scan, PET Scan or MRI, X-Rays 2,500 per visit Endoscopy (e.g., gastroscopy, colonoscopy, cystoscopy) Max 1 visit per day Laboratory Maxi 30 visits per year Outpatient or Ambulatory Surgery Alternative Medicine Not Covered Homeopathy and Acupuncture treatment for a covered Illness Sleep Studies/Tests and Treatment Not Covered for suspected conditions of Narcolepsy or Obstructive Sleep Apnea Traditional Chinese Treatment Consultation fee, diagnostic fee, Traditional Chinese Medicines Not Covered prescribed by a registered traditional Chinese physician Therapeutic Services Physical Therapy, Physiotherapy, Chiropractic Therapy, Vocational Not Covered Therapy, Speech Therapy, Occupational Therapy Ground Ambulance Fully Covered OPTIONAL BENEFITS War and Terrorism Benefit (Medical treatment subject to Deductible and Policy Co-payment for health plan)
(Medical treatment subject to Overall Inpatient Maximum or Overall Outpatient Maximum)
INCLUDED IN THIS PLAN Not covered Bodily Injury directly or indirectly caused by certain acts of War and Terrorism Wellness Benefits (Not subject to Deductible and Policy Co-payment for health plan)
(Not subject to Overall Outpatient Maximum)
INCLUDED IN THIS PLAN Not covered Costs of a full physical examination and the tests and procedures associated with such examination; Immunizations, routine tests and exams Dental Benefits (Not subject to Deductible and Policy Co-payment for health plan)
(Not subject to Overall Outpatient Maximum)
INCLUDED IN THIS PLAN Not covered Maximum Annual Benefit (Class I, Class II and Class III Dental Services) Class I Dental Services - Preventive 100% The insurance pays the stated percentage of Usual and Customary Charges for routine examinations, dental health instruction, fluoride treatment, scale and polish (prophylaxis), and cleaning of teeth (oral prophylaxis) up to two (2) times per Policy Year.
5 Class II Dental Services - Basic Restorative 80% The insurance pays the stated percentage of Usual and Customary Charges for amalgam or composite fillings, simple extractions, periodontal scaling, root planning and related pan oral x-ray. Class III Dental Services - Major Restorative 50% The insurance pays the stated percentage of Usual and Customary Charges for root fillings, root canal, crowns and inlays, bridges (including laboratory and anesthetic fees), wisdom teeth extractions, Orthodontic Treatment and related pan oral x- ray. Orthodontic Treatment - study models, impressions, removable string appliances (braces), fixed appliances (including adjustments), extractions, re-cementing of brackets. Dental Exclusions - Cosmetic surgery or supplies or procedures, false teeth, dental implants, onlays, veneers and all associated costs. Vision Benefits (Not subject to Deductible and Policy Co-payment for health plan)
(Not subject to Overall Outpatient Maximum)
INCLUDED IN THIS PLAN Not covered Examination (one per policy year) One pair of glasses or contact lenses (for disposables, multiple pairs may be reimbursed) Exclusions: Sunglasses and/or related accessories. Personal Accident INCLUDED IN THIS PLAN 100,000
6 Contact Us
Your Account Manager
Ms. Anchalee Dubey
Phone: 064-942-6592
LINE ID: anchaleedubey
For all enquiries
7 HSCDirect
HSCDirect provides you ease-of-mind on expenses settlement when you visit hospitals and clinics within our facility network. ⚫ Present your HSC membership card and your photo ID to hospital/clinic. (For juvenile patient under 16, please present ID for both patient and guardian.)
⚫ See doctor
⚫ Fill in and sign claim form. (For juvenile patient under 16, guardian please sign on behalf.)
⚫ Pay copayment/deductible/uncovered expenses according to your policy.
Things to remember
Please confirm personal particulars on your membership card. In case of any errors, please contact your HR department. If any personal information is updated, such as ID number, please update your HR department. If lost, please contact your HR department immediately. During re-issuance of membership card, please contact us for direct billing services before you visit a hospital/clinic. You are required to return your card back to HR department upon leaving your company/group. Always bring your ID (same as used at enrollment) and your direct billing membership card when you visit a hospital/clinic. Some facilities may not collect payment on site. You’ll be informed to pay back to facility or us after claim assessed.
For HSCDirect Network list, please refer to Appendix 1.
8 Pre-authorization
Please inform us at least 2 working days before any of the below treatment or examination, or within 48 hours if it is an emergency.
Hospitalization, day case & surger, including out-patient surgeries. All endoscopy exams
CT, MRI, PET scans and any single Examination above THB 10,000
Buy or rent durable equipments/devices, Kidney dialysis and cancer treatment y (including out-patient surgery)
Long term prescriptions over 90 days
Medical evacuation
Physiotherapy due to non-accidental causes.
⚫ How to apply Remember to prepare： Call us: 064-942-6592 ⚫ ID number ⚫ Membership card Email us:[email protected] ⚫ Medical certificate or record ⚫ Treatment plan, or any other Cc: [email protected] supporting document provided by medical provider.
⚫ Things to remember
Failure of obtaining pre-authorization on medical evacuation will cause full rejection on the evacuation.
The pre-authorization does not represent the final claim decision. The final decision is subject to review by Houghton Street Consulting.
9 ⚫ Pay and Claim If you visit a hospital/clinic where direct-billing service is not available, please pay for your medical expenses upfront, and submit your claim to us following the below instructions.
Document Collection
Required documents: • Complete a claim form and sign (please refer to the Appendix 2) • Copy of current identity document (same as used on enrollment), and copy of membership card • Original, official receipts or invoices • Copy of the breakdown bills • Copies of medical documents indicating the illness description such as medical records, discharge summary, examination results, and other relevant document
Submit claim
Scan all the documents and send to [email protected] cc: [email protected] for prompt processing. Drop the original copies to the HR office at your campus.
- We suggest saving copies for your reference.
Receive payment
Claim payments will be made into your chosen bank account (the account information you provide has to be the same as the account information with the bank).
10 Medical Advice
Stay with ease on any medical advice you need.
Travel health advice
Hospital/Doctor recommendation
Second medical opinion
Add-on Services
Let our add-on services to help you live a healthier and easier life.
Presription Auto Refill
Emergency assistance
Health talks
On-campus consultation
How to apply
Contact your Account Manager for more details.
11 Appendix 1. HSCDirect Network List HOSPITAL/CLINIC ADDRESS HOTLINE Bangkok Hospital Head 2 Soi Soonvijai 7, New Petchburi Road, 02-310-3000 Quarter (BHQ) Bangkok 13310 1308, 9 Mittraphap Rd, Amphoe Mueang 02-429-999 Bangkok Hospital Ratchasima Nakhon Ratchasima, Chang Wat Nakhon Ratchasima 30000 88/8-9 Moo 6 Mueang Chiang Mai 052 089 888 Bangkok Hospital Chiangmai District, Chiang Mai 50000 2 1 Soi Hongyok Utis, Tambon Talat Yai, 076 254 425 Bangkok Hospital Phuket Amphoe Mueang Phuket, Chang Wat Phuket 83000 038 259 999 301 หมู่ที ่ 6 Sukhumvit Rd, ตำบล หนองปรือ Bangkok Hospital Pattaya Amphoe Bang Lamung, Chang Wat Chon Buri 20150 Bangkok Hospital China Town 624 Yaowarat Road, Samphantawong, 02-118-7888 (BCT) Bangkok, 10100 02-686 2700 BNH 9/1, Convent Road, Silom Bangkok 10500 133 Sukhumvit 49, Klong Tan Nua, 02-022-2222 Samitivej Sukhumvit Hospital Vadhana, Bangkok 10110 488 Srinakarin Road, Suan Luang, 02-022-2222 Samitivej Srinakarin Hospital Bangkok 10250 488 Srinakarin Road, Suan Luang, 02-022-2222 Samitivej Children’s Hospital Bangkok 10250 Vejthani International 1 Ladprao Road 111, Klong-Chan 02-734-0000 Hospital Bangkapi, Bangkok 10240 Paolo Memorial Hospital 670/1 Phaholyothin Rd., Samsennai, 095-552-0337 Phaholyothin Phayathai, Bangkok 10400 The Racquet Club, 3rd Floor Bldg 2, 02-018-7855 MedConsult International Sukhumvit Soi 49/9, Clinic Khlong Tan Nuea, Bangkok, Thailand 10110 9/99 Ramintra (Km.8.5) Road, Kunnayao, 02-793-5000 Synphaet Hospital Kunnayao Bangkok 10230 943 Phaholyothin Rd., Samsennai, 02-617-2444 Phyathai 2 Hospital Phyathai, Bangkok 10400 ext.2047, 2048 44 Seri Thai road, Minburi, Bangkok 02-761-9888 Seriruk Hospital 10510
12 34/1 Issaraphap Rd. Banchanglor, 02-487 -2000 Thonburi1 Bangkoknoi, Bangkok,10700 1728 (Local calls 976 Lasalle Road, Bangna-Tai, Bangkok only) Sikarin 10260 Tel +662-366- 9900 02-363-2000 123 Moo. 8 Srinagarindra Rd, Bang Paolo Samutprakarn Meuang, Mueang Samut Prakan District Samut Prakan 10270
11/1 Rungsit Rd, Nakhon Na yok 02-577-8111 Paolo Rangsit Sub-distriact, Amphoe Thanyaburi, Chang Wat Pathum Thani 12130
430 Pisanulok Rd. Khet Dusit, Krung Thep 02-282-1100 Mission Maha Nakhon 1100 +66 (0)-2722- 2677 Phatthanakan Rd, Khwaeng Suan 2500 Vibharam Luang, Suan Luang, Bangkok 10250 +66 (0)-2032- 2550 02-173-7766 Soi Thetsaban 23, Tambon Pak Nam, Muang Samut Paknam Amphoe Mueang Samut Prakan, 10270
02-202-9999, 99 Rama IX Road, Khwaeng Bang Kapi Praram 9 1270 Huaykwang, Bangkok, 10310
02-530-2556 2699 Soi 6, Khwaeng Khlong 065-5132615 Ladprao Chaokhunsing, Wang Thonglang, (For English Bangkok 10310 spoken 24 hr) 345 Bang Na-Trat Rd, Khwaeng Bang Na, 02-361-2727 Thainakarin Khet Bang Na, Krung Thep Maha Nakhon 10110 345 Bang Na-Trat Rd, Khwaeng Bang Na, 02-361-2727 Khet Bang Na, Krung Thep Maha Nakhon 02-348-7000 Thainakarin 10110 Theptarin Hospital 3850 Rama IV Road, Klongtoey, Bangkok 10110 1308, 9 Mittraphap Rd, Amphoe Mueang 02-429-999 Bangkok Hospital Ratchasima Nakhon Ratchasima, Chang Wat Nakhon Ratchasima 30000
13 052 089 888 88/8-9 Moo 6 Mueang Chiang Mai Bangkok Hospital Chiangmai District, Chiang Mai 50000
2 1 Soi Hongyok Utis, Tambon Talat Yai, 076 254 425 Bangkok Hospital Phuket Amphoe Mueang Phuket, Chang Wat Phuket 83000
1 Sukkasem Road, Paton Subdistrict, 053-999- Lanna Hospital (Chiangmai) Nakornping, Muang District, Chiangmai 777/053-999- 50300 798
212/80-81(20,22) Soi Phatthanakan 64 02-321-9980 Phatthanakan Rd, Prawet, Bangkok Piyachat Clinic 10250 Pattakarn 64 Bangkok
40/1 Soi Sukhumvit 71, Phra Khanong, 02-711-0460 Central Medic Clinic Watthana, Bangkok 10110 02-066-8888 Bumrungrad Hospital 33 Sukumvit 3 Wattana Bangkok 10110
423 Sukumvit 55, North Klonggtun 02-185-1444 Camiillian Hosopital Vadhana, Bangkok 10110 053-200-002 157/16-19 หมู่ 10 ถ.เชียงใหม่-ฮอด Tambon Chiangmai Klaimor Hospital Pa Daet, Amphoe Mueang Chiang Mai, Chang Wat Chiang Mai 50100
Phyathai Sriracha General 90 Si Racha Nakhon 3, Amphoe Si Racha, 033-038888 Hospital Chang Wat Chon Buri 20110 038-488777 หมู่ที ่ 9 328/1 Central Pattaya Rd, Bang Pattaya Memorial Hospital Lamung District, Chon Buri 20150
124 Si Lom, Khwaeng Suriya Wong, Khet 02-625-9000 Bangkok Christian Hospital Bang Rak, Krung Thep Maha Nakhon 10500
89 / 8-9 Moo 2 Chaofa Rd Tambon 076-298298 Dibuk Hospital Wichit, Amphoe Mueang Phuket, Chang Wat Phuket 83000
1 Thailand Route 35, Khwaeng Samae 02-450-9999 Nakornthon Hospital Dam, Khet Bang Khun Thian, Krung Thep Maha Nakhon 10150
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02-594-0020 60 หมู่6 Kanchanaphisek Expy, Tambon Kaseamrad International Rathanatibate Bang Rak Phatthana, Amphoe Bang Bua Thong, Chang Wat Nonthaburi 11110
02-718-1515 2469 13,15 New Petchaburi Rd, Khwaeng Petchvej Hospital Bang Kapi, Khet Huai Khwang, Krung Thep Maha Nakhon 10310
02-033-2900 88/8-9 Thepharak km.14 road Bang Pla, Chularat 3 Hospital Bang Phli District, Samut Prakan 10540
586-588 Phet Kasem Rd, Khwaeng Bang 02-804-8959 Kasemrad Bangkae Hospital Khae Nuea, Khet Bang Khae, Bangkok 10160 02 804 8959 68/3 Phaya Satcha Rd, Tambon Ban 038-939-999 Aikchol Hospital Suan, Muang Chonburi Chang Wat Chon Buri 20000
We reserve the right to amend the list without prior notice. Should you need latest information or assistance, please contact us.
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Appendix 2. Claim Form
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