QUY TC BO HIM SC KHE MEDICAL CARE

(Ban hnh km theo Quyt nh s 1123 /2013/Q/TG-BHBV ca

Tng gim c Tng Cng ty Bo him Bo Vit)

NI DUNG
PHN 1
nh ngha ________________________________________________________________________2
PHN 2
Quyn li bo him _________________________________________________________________6
PHN 3
Cc im loi tr ___________________________________________________________________9
PHN 4
Cc iu khon chung _______________________________________________________________10
PHN 5
Th tc bi thng _________________________________________________________________13
PHN 6
Ph lc Danh sch cc bnh ngh nghip ______________________________________________14

Sn phm ca Tng Cng ty Bo him Bo Vit

PHN 1 NH NGHA
Cn c vo nhng iu kin v cc im loi tr quy nh trong n bo him ny hoc c b sung vo n bo him ny, Tng Cng ty
Bo him Bo Vit ng rng s bi thng cho Ngi c bo him nhng chi ph thuc trch nhim bo him pht sinh trong thi hn
bo him sau khi Ngi c bo him thanh ton y ph bo him cho Bo Vit.
Theo n bo him ny, cc t v cm t vit hoa c hiu nh sau:
BO VIT

Tng cng ty Bo him Bo Vit, ngi bo him.

a ch: 35 Hai B Trng, Hon Kim, H Ni.
Telephone: (84)-4- 39343125

Fax: (84)-4-38257188

Bnh vin

Bt k c s no c cp giy php hp php nh mt bnh vin tin hnh iu tr y t hay phu thut,
c xy dng ti nc s ti v hot ng chnh ca bnh vin khng phi l hot ng ca Bnh x,
ni iu tr sui khong hay iu tr xng hi, trung tm cai nghin ru, ma ty, Vin iu dng, Phng
khm hay Nh dng lo. Vic tin hnh iu tr phi c theo di lin tc bi Bc s.

Bnh vin cng lp

Bnh vin cng lp l bnh vin 100% vn Nh nc, c thnh lp v qun l bi c quan Nh nc c
thm quyn theo quy nh ca php lut Vit Nam.

Bc s

L nhng ngi hnh ngh y c bng cp c cng nhn bi lut php ca quc gia m ti bnh nhn
ang iu tr v l ngi chun on iu tr bnh ng thi ang thc hin cng vic trong phm vi giy
php hnh ngh v c o to nhng loi tr bc s l bn thn Ngi c bo him, v (chng), b
m, b m v/chng hoc con ca Ngi c bo him. Bc s c th l C vn y t hoc Bc s chuyn
khoa.

Bnh/thng tt c sn

L bnh hoc thng tt c t trc ngy bt u c nhn bo him theo Hp ng bo him v l

bnh/thng tt m ngi c bo him:
a. phi iu tr trong vng 3 nm gn y
b. triu chng bnh / thng tt xut hin hoc xy ra trc ngy k hp ng m Ngi c
bo him bit hoc thc c cho d Ngi c bo him c thc s khm, iu tr hay khng.
Bnh c sn bao gm nhng khng gii hn nhng bnh nh vim VA cn phi no, vim amidan cn
phi ct, vo vch ngn cn phu thut, ri lon tin nh, hen/suyn, vim tai gia phi phu thut.
Vic khng tit l thng tin v bnh/ thng tt c sn hoc cung cp thng tin sai lch v tin s bnh tt
c nhn ca (nhng) Ngi c bo him c th dn ti vic t chi Giy yu cu bo him, t chi bi
thng v/hoc hy b hoc v hiu Hp ng bo him.

Bng chng khiu ni

Bc s Chuyn khoa
/C vn y t

L thng bo hoc thng tin bng bt k hnh thc no ca Ngi c bo him cho Bo Vit v bt k
ri ro no xy ra i vi Ngi c bo him trong thi hn bo him.
Bc s c cp giy php hnh ngh hp php, c ng k theo Y php ph hp vi Lut php ca
quc gia v c Lut php quc gia s ti cng nhn l Bc s chuyn khoa/C vn y t.

Bnh c bit

L nhng bnh ung th v u cc loi, huyt p, tim mch, lot d dy, vim a khp mn tnh, lot rut,
vim gan cc loi, vim mng trong d con, tr, si trong cc h thng tit niu v ng mt, vim xoang,
Parkinson, bnh i tho ng, bnh lin quan n h thng ti to mu nh lc mu, thay mu, chy
thn nhn to, bnh thoi ha cc loi, thot v/lch/hp/li a m ct sng, hng cc b phn ni tng,
thiu hc mn sinh trng, c thu tinh th (cm mt).

Bnh ngh nghip

cp ti cc bnh c nguyn nhn t iu kin lm vic c hi nh hng ti sc khe ngi lao ng

v c th xy ra t t hoc cp tnh. Mt s bnh ngh nghip ngy cng trm trng m khng c bin
php cha tr trit v li di chng. Danh sch cc bnh ngh nghip c quy nh bi B Y t Vit
Nam.

B phn gi

L cc vt c lm gi thay th cho cc b phn ca c th bao gm nhng khng gii hn rng gi,

chn tay gi, thy tinh th gi ...

B phn thit b y t
h tr iu tr

L tt c cc b phn hay cc thit b c t/cy/trng vo bt c mt b phn no ca c th h tr

cho chc nng hot ng ca b phn , hay cc dng c y t dng h tr cho vic iu tr hoc phu
thut, bao gm nhng khng gii hn a m, np, vis trong phu thut kt xng, my h tr tim, dao
ct tr theo phng php m Longo, stent trong phu thut nong ng mch, cc dng c h tr chc nng
vn ng nh nng, xe y, thit b tr thnh, knh thuc v cc dng c chnh hnh mang tnh cht thm
m khc...

Sn phm ca Tng Cng ty Bo him Bo Vit

Bin chng thai sn

iu tr y t pht sinh trong khong thi gian mang thai hoc sinh n v cc th thut ca sn khoa (loi
tr m theo yu cu). Bin chng thai sn bao gm v khng gii hn trong cc trng hp sau:
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)

Cy ghp ni tng

Cng ty cu tr do
Bo Vit ch nh

Sy thai hoc thai nhi cht trong t cung;

Thai trng;
Thai ngoi t cung;
Bng huyt sau khi sinh;
St nhau thai trong t cung sau khi sinh;
Ph thai do iu tr;
Sinh kh;
Bin chng ca cc nguyn nhn trn.

L vic phu thut cy ghp tim, phi, gan, tuyn tu, thn hoc tu xng cho Ngi c bo him
c tin hnh ti mt bnh vin bi Bc s c bng cp c php thc hin loi phu thut ny. Cc chi
ph mua c quan cy ghp v ton b cc chi ph pht sinh cho ngi hin b phn c th khng c bo
him theo n bo him ny.
Cng ty cu tr quc t International SOS Pte Ltd. (ISOS) c u quyn v hot ng nhn danh Bo
Vit.
a ch: 51 Xun Diu, Ty H, H Ni
S in thoi: (84)-4-9340555; Fax: (84)-4-9340556

Chi ph c thanh ton

Nhng chi ph y t cn thit pht sinh iu tr cho Ngi c bo him trong trng hp thng tt,
m au, hay bnh tt trong thi hn bo him nhng khng vt qu gii hn ti a mc trch nhim quy
nh trong n bo him.

Chi ph y t ti nh

Dch v chm sc y t ti ni ca Ngi c bo him do mt y t c cp giy php hnh ngh hp

php thc hin v l do chm sc y t khc vi gip vic gia nh, theo ch nh ca Bc s iu tr ngay
sau khi Ngi c bo him iu tr ni tr trong bnh vin. Thi hn iu tr c gii hn ti a
khng qu s ngy quy nh trong chng trnh bo him la chn, vi iu kin Ngi c bo
him c iu tr ti thiu 7 ngy trong bnh vin.

Chi ph bnh vin

tng hp

Chi ph thng l
v hp l

Nhng chi ph v dch v y t hay dc phm cung cp bi bnh vin, vi iu kin nhng chi ph phi
l chi ph thng l, hp l nhng khng vt qu mc trch nhim bo him bao gm:
(i)
Thuc v dc phm s dng trong khi nm vin;
(ii)
Qun o, bng, np thng thng v bt;
(iii)
Xt nghim;
(iv)
in tm ;
(v)
Xt nghim chuyn ho c bn;
(vi)
Vt l tr liu;
(vii)
Liu php X-quang, liu php radi; radi v ng v;
(viii)
Xt nghim X-quang;
(ix)
Tim truyn tnh mch;
(x)
Chi ph hnh chnh v chi ph mu, huyt tng;

Nhng chi ph khng vt qu mc chi ph chung ca cc nh cung cp dch v y t c cng iu kin

trong khu vc, ni pht sinh nhng chi ph , khi cung cp cc dch v iu tr tng ng hoc mc
iu tr, dch v i vi bnh tng t hoc thng tt thn th gy ra bi tai nn.

Chi ph phu thut

n bo him ny s thanh ton ton b nhng chi ph (loi tr cy ghp ni tng) phi tr cho mt cuc
phu thut do mt hoc mt vi bc s tin hnh. Tuy nhin tng s tin chi tr cho tt c cc phu thut s
khng vt qu Gii hn ti a v Chi ph phu thut qui nh trong Bng quyn li bo him. Chi ph
phu thut c hiu bao gm chi ph chn on trc phu thut v chi ph chm sc thng thng sau
phu thut.

iu tr ni tr cho tr s sinh

L cc chi ph y t cn thit cho vic iu tr ni tr cho tr s sinh lin quan n nhng triu chng xut
hin khi sinh hoc c biu hin trong vng 7 ngy sau khi sinh vi iu kin ngi m vn nm vin.

Dch v bnh vin

L cc dch v y t cung cp cho Ngi c bo him khi cc bin php chn on hp l v/hoc iu
tr ngoi tr khng th cung cp c v khi Ngi c bo him c chp nhn iu tr ni tr trn 24
gi. Dch v ti bnh vin bao gm chi ph thng l v hp l ti ni cho cc phng tin y t, cc iu
tr v dch v y t cung cp bi Bc s, bao gm c chm sc y t c bit khi cn thit.

Dch v xt nghim
v chp X quang

Dch v xt nghim, th thut dng x-quang v y hc ht nhn chn on v iu tr. Dch v xt

nghim v chp x-quang phi theo ch nh ca Bc s. Quy tc bo him ny s thanh ton theo chi ph
hp l cho nhng dch v do Bc s tin hnh.

Sn phm ca Tng Cng ty Bo him Bo Vit

Dch v vn chuyn cu thng L vic s dng xe cu thng ca bnh vin/phng khm hoc phng tin vn chuyn khc (khng phi
l dch v vn chuyn bng ng hng khng) trong trng hp Ngi c bo him trong tnh trng
m au/tai nn nguy kch nh hng n tnh mng buc phi a ngi bnh n iu tr ti phng cp
cu ca Bnh vin/phng khm gn nht hoc t bnh vin ny n bnh vin khc.
i dch

Bnh ly nhim do mt chng vi rt gy ra pht trin v ly lan nhanh chng v c th gy nhim bnh
hoc t vong cho rt nhiu ngi trong mt quc gia hoc trn ton th gii.

iu tr ngoi tr

Dch v iu tr y t cung cp cho Ngi c bo him, khi Ngi c bo him phi iu tr ti bnh
vin hoc Trung tm y t di 24 gi. Dch v iu tr ngoi tr bao gm cc dch v do Bc s a khoa,
Bc s chuyn khoa hay C vn y t iu tr cho Ngi c bo him hoc thc hin theo ngh ca mt
Bc s khc. Cc dch v ny bao gm xt nghim, th thut s dng x-quang v y hc ht nhn chn
on, iu tr bnh v c thc hin theo ch nh ca Bc s.
Dch v iu tr ngoi tr bao gm c thuc iu tr do Bc s k n.

iu tr ngoi tr/rng
cp cu do tai nn gy ra

Nu Ngi c bo him b thng do tai nn dn n cn phi iu tr ngoi tr hoc iu tr rng cp

cu cho nhng rng kho t nhin ti bnh vin trong vng hai t (24) gi k t khi tai nn xy ra, th Bo
Vit s thanh ton nhng chi ph hp l cn thit cho nhng iu tr nhng ti a khng vt qu mc
gii hn qui nh ca quyn li Chi ph y t do m au, bnh tt, tai nn trong Bng quyn li bo him.

iu tr ni tr

L vic mt Ngi c bo him nhp vin pht sinh cc chi ph nh chi ph trc khi nm vin, chi ph
nm vin, chi ph iu tr/phu thut trong ngy, chi ph phu thut, chi ph sau khi xut vin, chi ph y t
chm sc ti nh hoc cc quyn li khc (nu c) theo cc gii hn quy nh trong Bng tm tt hp ng
bo him.

iu tr trc khi nhp

vin

Hi chn ca Bc s v cc qu trnh chn on cn phi tin hnh v c lin quan trc tip ti mt tnh
trng y t cn phi nhp vin ngay lp tc. Kt qu ca hi chn l c s bc s khm bnh kt lun cn
phi nhp vin iu tr vi iu kin cc hi chn phi c thc hin trong vng 30 ngy trc ngy
nhp vin.

iu tr sau khi ra vin

iu tr tip theo do Bc s ch nh ngay sau khi ra khi bnh vin ni tin hnh iu tr nm vin.
iu tr sau khi ra vin bao gm hi chn vi Bc s, xt nghim, kim tra, k thuc theo toa v c thc
hin trong vng 45 ngy k t ngy ra vin.

iu tr cp cu

L vic iu tr khn cp ti c s y t trong vng 24h sau khi c tai nn hoc triu chng m au/bnh tt
c th nguy him n tnh mng, sc khe cn thit phi iu tr khn cp ti phng cp cu, c pht sinh
chi ph ging bnh v h s c du xc nhn cp cu ca c s y t.
Trng hp iu tr ti phng cp cu ch v l do ngoi gi phc v ca phng khm/ bnh vin th c
coi l iu tr ngoi tr.

iu tr/phu thut trong ngy Ngi c bo him c nhp vin iu tr/phu thut c pht sinh chi ph ging bnh nhng khng
lu li bnh vin qua m.
ng bo him

L phn Chi ph c thanh ton m Ngi c bo him phi t chu. Mc ng bo him v cc mc

bo him p dng Mc ng bo him c ghi c th trong Giy chng nhn bo him, Bng tm tt
iu kin bo him hoc n bo him.

Gii hn chi tit (ph)

Quyn li bo him ti a p dng cho mi s kin bo him trong n bo him, c qui nh chi tit
trong Bng quyn li bo him.

Hp ng bo him

L Hp ng gia Bo Vit v Ngi c bo him, theo cung cp dch v bo him nh trong n

bo him ny. Hp ng bo him bao gm Giy yu cu bo him, Giy khm sc kho ti thi im
tham gia bo him (nu c), Bng tm tt iu kin bo him v / hoc Giy chng nhn bo him v n
bo him ny, tt c cc ti liu ny c coi nh mt b Hp ng bo him thng nht.

Ln khm

Mt ln khm bnh l mt ln ngi bnh c Bc s thm khm lm sng, xt nghim, chn on hnh
nh, thm d chc nng hay cc th thut thm d khc, thuc iu tr trong cng mt c s y t nhm
mc ch chn on bnh v iu tr. Trng hp nhiu Bc s chuyn khoa cng hi chn trc mt
ngi bnh theo qui ch bnh vin th ch c tnh l mt ln khm bnh. Trng hp ngi bnh khm
mt chuyn khoa nhiu ln trong ngy th ch tnh l mt ln khm bnh. Ring trng hp ngi bnh
phi khm thm mt s chuyn khoa khc d c ch nh ca Bc s trong cng mt c s y t, trong mt
ln khm bnh th vn tnh l mt ln khm bnh.

Mi thng tt

Tt c cc thng tt pht sinh t cng mt nguyn nhn bao gm c cc bin chng t cc thng tt .

Sn phm ca Tng Cng ty Bo him Bo Vit

Nm vin

L vic bnh nhn cn thit nm ti bnh vin t nht l 24 gi v/hoc qua m iu tr cho n khi ra
vin. Trong trng hp bnh vin khng cp c Giy nhp vin hoc xut vin, h s y t hoc ha n
thanh ton th hin r thi gian iu tr s c coi nh chng t thay th. n v ngy nm vin c
tnh bng 24h hoc theo n v ging nm trong Giy ra/ xut vin hoc trong chng t vin ph chi tit.

Ngy hiu lc

Ngy bt u bo him hoc ti tc bo him ca hp ng bo him ghi trn Giy chng nhn bo him
hoc Bng tm tt iu kin bo him.

Ngi ph thuc

V (chng) (loi tr trng hp ly d), b m, b m v/chng v/hoc con ngoi gi th, con ring, con
c nhn v nui dng v con nui hp php sng ph thuc vo Ngi c bo him vi iu kin
nhng ngi con ny nm trong tui t 1 tui n 18 tui hoc 23 tui nu ang theo hc cc kho hc
lin tc di hn v cha kt hn.

Ngi c bo him

C nhn hon thnh vic k khai, hoc tn ca h c k trong Giy yu cu bo him v hiu lc bo
him c xc nhn, hoc l ngi c cp Giy chng nhn bo him, nhng vi iu kin ngi
khng ri khi ni c tr qu mt trm tm mi (180) ngy lin tc trong mt thi hn bo him.

Ni c tr

Bt k thnh ph hay tnh no Vit nam m Ngi c bo him khai trong Giy yu cu bo him
hoc c chp thun v ghi trong Giy chng nhn bo him hay Bng tm tt iu kin bo him.

m au, Bnh tt

C ngha l mt tnh trng c th c s khc bit v bnh l so vi tnh trng sc khe bnh thng.

Phng v ging bnh

Cc chi ph tin ging nm iu tr trong mt phng n () v cc khon chi ph lin quan khc, bao gm
c phng chm sc c bit v cc chi ph chm sc y t cn thit khc do mt y t c bng cp chm sc.
Trong mi trng hp, Bo Vit ch thanh ton chi ph cho mt ging n phc v iu tr m au, bnh
tt, tai nn cho Ngi c bo him, khng thanh ton chi ph tin ging cho ngi nh n chm sc.

Phng chm sc c bit

Trong trng hp Ngi c bo him phi nm iu tr trong phng chm sc c bit ca bnh vin,
Bo Vit s thanh ton chi ph phng v ging bnh hng ngy nhng khng vt qu mc gii hn ti
a c nu trong Bng quyn li bo him.

Phu thut

L mt phng php khoa hc iu tr thng tt hoc bnh tt c thc hin bi nhng phu thut
vin c bng cp thng qua nhng ca m bng tay vi cc dng c y t hoc bng thit b y t trong bnh
vin bao gm nhng khng gii hn bi m ni soi, m bng tia laser...

Phm vi lnh th

Phm vi lnh th cho mi chng trnh bo him nh qui nh trong Bng Quyn li bo him, bao gm
(i) ni Ngi c bo him c th c vn chuyn ti khi cn cp cu khn cp v khi nhng iu tr
cn thit khng th c c ti ni tnh trng khn cp xy ra v (ii) l ni nhng chi ph y t thng l
v cn thit m Ngi c bo him phi chi tr c th c xt bi thng theo bo him ny. Trong
trng hp m rng phm vi lnh th ra nc ngoi, Bo Vit s bo him cho cc trng hp b tai nn/
m au, bnh tt v nhng chi ph y t lin quan pht sinh trong phm vi lnh th theo ng chng trnh
bo him tham gia, khng bo him cho chi ph i li (tr trng hp Ngi c bo him b tai nn
dn n tnh trng sc khe nguy him, e da n tnh mng v c tham gia quyn li Vn chuyn y t
cp cu), chi ph n v cc chi ph khc ca Ngi c bo him.

Qu hng

L quc gia m Ngi c bo him sinh ra v/hoc l cng dn hp php.

Tai nn

Bt k s kin bt ng, khng lng trc, gy ra bi mt lc t bn ngoi, mnh v c th nhn thy c

xy ra trong thi hn bo him, dn n thng tt thn th cho Ngi c bo him v nm ngoi s
kim sot ca Ngi c bo him.

Tn tt do m au, bnh tt

L mt s bin i v th cht v tinh thn lm cho Ngi c bo him khng th thc hin c mt
phn hoc ton b cc nhu cu c nhn, x hi hay cng vic, hoc p ng c nhng yu cu ca Lut
php hay cc Quy nh khc.

Thng tt thn th

Thng tt thn th do tai nn gy ra trong thi hn bo him dn n Ngi c bo him b thng tt

hoc tn tt.

Thuc k theo n

L nhng thuc, dc phm c bn v s dng theo n ca Bc s v theo quy nh ca php lut,

khng bao gm thc phm chc nng, dc m phm v cc loi vitamin tr trng hp cc loi vitamin
c ch nh chung vi thuc iu tr v chi ph cho cc loi vitamin ny khng ln hn chi ph thuc
iu tr

Tnh trng sc kho nguy him/

Tnh trng e da n tnh mng

Tnh trng sc kho m theo kin ca Cng ty cu tr v / hoc Bo Vit l nguy kch cn phi iu tr
khn cp trnh t vong hay nh hng nghim trng ti tnh trng sc kho hin ti v lu di ca
Ngi c bo him. Tnh trng sc kho nguy kch s c nh gi theo hon cnh ca a phng,

Sn phm ca Tng Cng ty Bo him Bo Vit

bn cht ca iu tr khn cp v kh nng cung cp dch v y t cng nh c s vt cht ti a phng

.
Thng tt tm thi

L tnh trng m Ngi c bo him b thng tt khng th thc hin c mt phn hoc ton b
nhim v lin quan n cng vic ca mnh trong mt khong thi gian no , nhng tnh trng thng
tt khng phi l vnh vin.

Tng hn mc trch nhim

Tng quyn li bo him gp c chi tr theo Quyn li Chnh m Ngi c bo him la chn khng
vt qu hn mc trch nhim quy nh trong Giy chng nhn bo him hoc Bn tm tt iu kin bo
him.

Thi gian ch

C ngha l thi gian m cc quyn li bo him c lin quan khng c chi tr bo him

Vn chuyn cp cu

Vic vn chuyn y t cp cu c Cng ty cu tr cung cp trong trng hp Thng tt thn th do tai

nn.
PHN 2 - QUYN LI BO HIM

A.

QUYN LI CHNH

Quyn li bo him c cp trong Bng quyn li bo him chi tr cho Ngi c bo him trong trng hp Thng tt thn th
v/hoc m au hay Bnh tt xy ra trong Thi hn bo him nh quy nh trong n bo him ny.
Khi nhn c Bng chng khiu ni, Bo Vit s chi tr Quyn li bo him thuc phm vi n bo him ny cn c theo Gii hn ph ti
mc Tng hn mc trch nhim ca n bo him c ghi trong Bng tm tt iu kin bo him hoc Giy chng nhn bo him. Cc
quyn li bo him trn c gii hn theo chi ph thc t, thng l, cn thit v hp l.
i din hp php ca Ngi c bo him c quyn thc hin thay mt cho Ngi c bo him khi Ngi c bo him b mt nng
lc php l hoc b cht. Quyn li bo him c th thanh ton cho Ngi c bo him, i din hp php ca h, hoc ngi c y
quyn, hoc nhng ngi c php cung cp dch v iu tr y t v/hoc chm sc y t v/hoc cc dch v phc v cho Ngi c bo
him. Bo Vit cng c th ch nh chuyn vin bi thng c lp i din v thay mt Bo Vit gii quyt bi thng cho Ngi c bo
him.

Mc 1 Chi ph y t do m au/ bnh tt/ tai nn

Nm vin:
Trng hp Ngi c bo him phi nm vin do m au, Bnh tt hay Tai nn trong thi hn bo him, Bo Vit s thanh ton ton b
chi ph y t thc t hp l v hp l v cc chi ph dch v y t bnh vin pht sinh trong qu trnh iu tr trong thi hn bo him, chi ph
phng v ging bnh, chi ph bnh vin tng hp nhng tng cng khng vt qu gii hn trch nhim ca quyn li la chn theo
chng trnh c quy nh trong Giy chng nhn bo him hoc Bng tm tt iu kin bo him.
Phu thut:
Trng hp Ngi c bo him phi phu thut hoc cy ghp ni tng, Bo Vit s thanh ton ton b cc chi ph hi chn, gy m, hi
sc v chi ph phu thut. Gii hn s tin chi tr cho chi ph phu thut hoc Cy ghp ni tng khng vt qu mc trch nhim i vi
quyn li bo him tng ng ca chng trnh la chn c quy nh trong Giy chng nhn hoc Bng tm tt iu kin bo him.
Mc 2 Cc quyn li khc
Ngoi ra, Bo Vit s thanh ton cho Ngi c bo him cc chi ph i y ty theo gii hn tng ng ca chng trnh bo him c
la chn:
1.

Chi ph khm v iu tr trc khi nhp vin: Chi ph y t v cc chi ph lin quan trong vng 30 ngy trc khi nhp vin.

2.

Chi ph khm v iu tr sau khi xut vin: Chi ph y t v cc chi ph lin quan trong vng 45 ngy sau khi xut vin.

3.

Chi ph y t ti nh: Ch bao gm chi ph thu y t c ch nh ca Bc s hoc bnh vin chm sc hoc h tr bnh nhn ti nh
trong thi hn 15 ngy sau khi xut vin.

4.

Tr cp nm vin: Ch p dng khi Ngi c bo him nm vin ni tr v chi tr theo gii hn trch nhim quy nh trong Bng
quyn li bo him. Trong trng hp Ngi c bo him iu tr ti bnh vin cng lp, quyn li ny s c chi tr gp i so vi
mc quy nh trong Bng quyn li bo him ca chng trnh la chn.

5.

iu tr/phu thut trong ngy: Chi tr chi ph thc t pht sinh v ti a khng vt qu gii hn trch nhim ca quyn li chi ph nm
vin hoc chi ph phu thut.

Sn phm ca Tng Cng ty Bo him Bo Vit

6.

Dch v vn chuyn cu thng: Trn phm vi lnh th Vit Nam ngoi tr vic vn chuyn bng my bay.

7.

Tr cp mai tng: Chi tr theo gii hn trch nhim quy nh trong Bng quyn li bo him trong trng hp Ngi c bo him t
vong do m au, bnh tt hoc tai nn c iu tr ni tr trc .

B.

QUYN LI B SUNG

Nhng quyn li b sung sau y ch c p dng trong trng hp c ghi r rng l c bo him trong Bn tm tt iu kin bo him
hoc Giy chng nhn bo him him v c gii quyt bi thng cn c vo cc nh ngha, cc im loi tr c quy nh trong phn
Quyn li chnh ca n ny nu khng c qui nh no khc.
QUYN LI B SUNG 1: TR CP NGY
Bo him Bo Vit s bi thng cho Ngi c bo him mt khon tr cp trong thi gian Ngi c bo him iu tr ni tr v/hoc
ngoi tr do tai nn, v iu tr ni tr do m au, bnh tt trn c s s ngy ngh theo ch nh ca Bc s iu tr hoc trn c s s ngy
ngh thc t theo giy nhp vin v xut vin (bao gm c ngy th by, ch nht v ngy l) nu Ngi c bo him iu tr ni tr vi s
ngy t hn s ngy ngh c ch nh.
Trong mi trng hp, s ngy ngh phi c ch nh ca Bc s iu tr. Trng hp iu tr ni tr, phi c giy nhp vin v xut vin.
Trng hp b tai nn, phi c bin bn tai nn c xc nhn ca c quan/chnh quyn a phng hoc cng an ni Ngi c bo him b
tai nn trong trng hp Ngi c bo him b tai nn nghim trng hoc bn tng trnh tai nn trong cc trng hp tai nn khc. Gii
hn trch nhim/ngy/ngi (bao gm c ngy th by, ch nht, v ngy l) c quy nh c th trong Bng Quyn li/Giy chng nhn
bo him v/hoc Hp ng bo him nh km.
QUYN LI B SUNG 2: IU TR NGOI TR
Theo iu khon b sung ny, Bo Vit s thanh ton cho Ngi c bo him cc chi ph y t pht sinh iu tr ngoi tr do m au, Bnh
tt hay Tai nn trong thi hn bo him nhng khng vt qu Mc gii hn quyn li bo him c nu trong Giy chng nhn bo him
hoc Bn tm tt iu kin bo him, bao gm:
1.
Tin khm bnh, tin thuc theo k n ca Bc s (ho n tin thuc phi th hin ng s lng thuc v liu thuc do Bc s iu
tr ch nh), tin chp X-quang v lm cc xt nghim chn on thng tt, m au bnh tt do Bc s ch nh.
2.

Cc bin php h tr y t cn thit trong qu trnh cha tr gy chn, tay hay cc thng tt, tn tt khc (bng, np, bt) v cc
phng tin h tr i b c Bc s ch nh.

3.

Php cha bng tia X, vic tr liu hc bc x hoc liu php nh sng v cc phng php iu tr tng t khc do Bc s ch nh.

QUYN LI B SUNG 3: CHM SC RNG

Theo iu khon b sung ny, Bo Vit s thanh ton cho Ngi c bo him cc chi ph cho vic iu tr rng bao gm khm v chn
on bnh, ly cao rng, trm rng bng cc cht liu thng thng nh amalgam, composite, fuji v cc cht liu tng ng khc, nh
rng su, nh nhng rng b nh hng, rng b ph nu hoc khng th mc c, nh chn rng, ly u vi rng (ly vi rng su di
nu), phu thut ct chp rng, cha ty rng, iu tr vim nu, vim nha chu.

QUYN LI B SUNG 4: THAI SN V SINH

Bo him s bi thng cc chi ph lin quan ti:
-

Bin chng thai sn nh nh ngha.

Trng hp sinh thng thng v m , Bo Vit chu trch nhim chi tr ton b chi ph thc t pht sinh cho mi khiu ni
bi thng nu Ngi c bo him la chn iu tr ti cc bnh vin cng lp Vit Nam hoc 70% chi ph y t thc t pht
sinh cho mi khiu ni bi thng nu Ngi c bo him la chn iu tr ti cc bnh vin khc, nhng trong mi trng hp,
s tin c chi tr khng vt qu gii hn trch nhim ca quyn li b sung ny qui nh trong Bng quyn li bo him. Trong
mi trng hp m , loi tr cc chi ph pht sinh thm do yu cu ca Ngi c bo him v gia nh nh chn bc s, chn
gi sinh.

iu tr ni tr cho tr s sinh.

QUYN LI B SUNG 5: VN CHUYN Y T CP CU

Theo quyn li b sung ny, bo him c m rng cung cp nhng dch v cn thit theo lit k di y xy ra trong phm vi lnh th
ca chng trnh la chn khi Ngi c bo him b tai nn khi ra khi ni c tr khai bo khng qu mt trm tm mi (180) ngy
lin tc trong mi thi hn bo him. Gii hn chi ph vn chuyn ti a khng vt qu Mc trch nhim c ghi trong Giy chng nhn
bo him hoc Bn tm tt iu kin bo him v tun th cc iu kin nu di y.

Sn phm ca Tng Cng ty Bo him Bo Vit

I.

QUYN LI

1.

H tr tin nhn khn cp

Trong trng hp khn cp hay nhp vin, khi c yu cu ca Ngi c bo him, cng ty cu tr s chu trch nhim thng bo cho
ngi nh ca Ngi c bo him bit.

2.

H tr dch v y t
Cng ty Cu tr, khi c yu cu, s cung cp tn, a ch, s in thoi v, nu c th, gi lm vic ca Bc s, bnh vin, phng khm,
nha s, phng khm rng trong phm vi lnh th ca chng trnh (gi chung l Ngi cung cp dch v y t). Cng ty cu tr s
khng trc tip iu tr hay chn on v mc d Cng ty cu tr cung cp nhng thng tin trn nhng quyn quyt nh la chn
Ngi cung cp dch v y t thuc v Ngi c bo him. Tuy nhin Cng ty cu tr s c gng ht sc v cn trng khi t vn
Ngi cung cp dch v y t cho Ngi c bo him.

3.

Bo lnh thanh ton cc chi ph y t pht sinh trong thi gian nm vin, theo di sc kho trong v sau khi nm vin.
Ngi c bo him c tham gia quyn li Chi ph y t, nu phi nhp vin th Cng ty cu tr s gip thu xp nhp vin cho Ngi
c bo him khi h yu cu. Cng ty cu tr cng, khi c y quyn ca Bo Vit, thay mt Bo Vit bo lnh thanh ton vin ph cho
Ngi c bo him trong phm vi quyn li Chi ph y t m Ngi c bo him c hng ti mc Gii hn Chi ph Y t c
quy nh trong Bn tm tt iu kin bo him hoc Giy chng nhn bo him. Ngoi ra, Cng ty cu tr s gim st tnh trng sc
kho ca Ngi c bo him cng vi Bc s iu tr, v s m bo tun th ngha v bo mt thng tin v thc thi trch nhim
trong phm vi quyn hn cho php.

4.

Thu xp v thanh ton cc chi ph vn chuyn y t cp cu.

Cng ty cu tr s thu xp vn chuyn cu tr bng my bay/ng b, chm sc ngi bnh trong khi di chuyn, trao i thng tin v
ngi bnh, thit b ph tr cn thit cho vic di chuyn cp cu Ngi c bo him ang trong tnh trng nguy kch ti mt bnh
vin gn nht, trong phm vi lnh th ca chng trnh bo him chn. Bo Vit s thanh ton cc chi ph cn thit lin quan ti vic
di chuyn cp cu, trao i thng tin hay ph ph cho vic di chuyn cp cu trn.
Cng ty cu tr c quyn quyt nh liu tnh trng sc kho ca Ngi c bo him nguy cp n mc phi vn chuyn cp cu
hay khng. Ngoi ra, Cng ty cu tr cng c quyn quyt nh a im vn chuyn Ngi c bo him n, v cc phng tin
cng nh phng thc vn chuyn da trn hon cnh thc t pht sinh m Cng ty cu tr nhn bit c ti thi im .
Vn chuyn cp cu ch c thc hin khi nhng iu tr cn thit khng th thc hin ni xy ra tai nn v vi iu kin l phi c
s ph chun bng vn bn ca Bo Vit trc khi vn chuyn v chng nhn ca bc s hoc chuyn gia iu tr khng nh rng nhng
iu tr cn thit khng th c c ti ni xy ra tai nn.

5.

Thu xp v thanh ton cc chi ph hi hng y t cp cu

Cng ty cu tr s thu xp hi hng cho Ngi c bo him v ni c tr ca h trn lnh th Vit Nam sau khi vn chuyn cp
cu. Bo Vit s thanh ton cc chi ph cn thit, hp l pht sinh trong qu trnh thc hin dch v .
Cng ty cu tr cng c quyn quyt nh phng tin hay phng thc vn chuyn hi hng da trn hon cnh thc t pht sinh m
Cng ty cu tr nhn bit c trong thi im .

6.

Thu xp v thanh ton hi hng thi hi

Cng ty cu tr s thu xp vn chuyn thi hi Ngi c bo him t ni t vong tr v ni c tr ca h hoc thu xp mai tng ti ni
t vong theo ngh ca thn quyn v vi s chp thun ca Bo Vit. Bo Vit s thanh ton tt c cc chi ph cn thit v hp l pht
sinh cho vic hi hng hay mai tng.

II. TRCH NHIM CA NGI C BO HIM TRONG TRNG HP H TR CP CU.

1. Yu cu cu tr
Trong trng hp khn cp, Ngi c bo him hoc Ngi i din phi gi in ngay lp tc n trung tm cu tr ca Cng ty cu tr
SOS di y:
a im thng trc

S in thoi

S Fax

167A Nam K Khi Ngha, Qun 3, TP H Ch

Minh, Vit Nam

(84) 8 3823 24 29

(84) 8 38298 551

Trc khi cng ty cu tr c th quyt nh bin php tr gip, Ngi c bo him cn phi cung cp nhng thng tin sau y khi lin h:

Tn Ngi c bo him, s Giy chng nhn bo him/Hp ng bo him v thi hn bo him.

S in thoi v a ch lin h vi Ngi c bo him.

M t vn tt tnh trng v bn cht ca tnh trng cn c cu tr.

Sn phm ca Tng Cng ty Bo him Bo Vit

2. Trng hp e da tnh mng

Trng hp tnh mng ca Ngi c bo him trong tnh trng nguy kch, Ngi c bo him hoc Ngi i din ca h phi c
gng thu xp vn chuyn cp cu ti mt bnh vin gn nht ni xy ra tai nn bng phng tin thch hp nht, v thng bo cho cng ty
cu tr cng sm cng tt.
3. Nhp vin trc khi thng bo cho cng ty cu tr
Trng hp Ngi c bo him b thng tt thn th cn thit phi nhp vin, Ngi c bo him hoc Ngi i din ca h phi
thng bo cho Cng ty cu tr bit trong vng 24 gi k t thi im xy ra s kin bo him. Trng hp khng thc hin thng bo trong
thi hn quy nh trn, Bo Vit c quyn yu cu Ngi c bo him phi chu mt phn chi ph vt tri khng hp l pht sinh do vic
thng bo chm tr .
4. Trng hp yu cu vn chuyn y t cp cu
Nu Ngi c bo him yu cu vn chuyn y t cp cu hoc hi hng, cc iu kin sau y phi c tun th:
a.

b.

gip trung tm cu tr c bin php kp thi, Ngi c bo him hoc Ngi i din ca h phi thng bo:

Tn, a ch, s in thoi ca bnh vin m Ngi c bo him c chuyn n

Tn, a ch, s in thoi ca bc s iu tr v bc s gia nh (nu c).

Nhm chuyn gia y t ca Cng ty cu tr c php tip xc vi Ngi c bo him nm c tnh trng sc khe ca h.

Nu Ngi c bo him khng tun th trch nhim trn, Ngi c bo him s khng c nhn bt k mt hnh thc cu tr y t no,
tr khi c l do hp l chng minh rng h khng th thc hin c ngha v trn.

PHN 3 - CC IM LOI TR
(p dng chung cho quyn li chnh v tt c cc quyn li b sung)
Cc phng php iu tr bnh, hng mc, iu kin, hot ng sau y v cc chi ph lin quan hay pht sinh mang tnh cht hu qu cu
chng s b loi tr trong n bo him ny v Bo Vit khng chu trch nhim i vi:
1.

Bnh c bit, bnh c sn trong nm u tin hp ng c hiu lc;

2.

Ri ro lin quan n ti to dy chng, rch sn chm trong hai (02) nm u tin hp ng c hiu lc. T nm th ba (03) tr i, cc
ri ro ny s c chi tr 80% chi ph thc t pht sinh, nhng khng vt qu gii hn ca quyn li tng ng.

3.

iu tr nhng bnh ly nhim qua ng tnh dc (bao gm nhng khng gii hn bnh lu, giang mai, herpes sinh dc), st rt, lao
v bnh ngh nghip;

4.

iu tr v/hoc phu thut cho cc bnh di truyn, d tt, khuyt tt, bnh bm sinh, bnh d dng v gien, nhng ch nh phu thut c
t trc ngy bt u bo him;

5.

iu tr bnh tm thn/ thn kinh hoc ri lon tm thn iu tr ri lon gic ng, mt ng, suy nhc v hi chng cng thng
(stress) hoc cc bnh c lin quan t hi chng ;

6.

iu tr hoc kim tra cc bnh lin quan n bnh hi chng suy gim min dch (AIDS), cc hi chng phc tp lin quan n AIDS
(ARC), hoc hu qu ca bnh AIDS khc;

7.

iu tr kim sot trng lng c th (tng hoc gim cn);

8.

iu tr rng hoc phu thut khoang ming, tr vic iu tr rng khn cp sau mt tai nn hoc khi Ngi c bo him tham gia
quyn li b sung v iu tr rng;

9.

Cc dch v iu tr ngoi tr tr nhng iu tr ngoi tr khn cp pht sinh do tai nn hoc khi Ngi c bo him tham gia quyn
li b sung v iu tr ngoi tr;

10. Mang thai hoc sinh con, tr khi Ngi c bo him tham gia quyn li b sung v thai sn v sinh ;
11. Kim tra sc khe nh k (ni tr hay ngoi tr); Gim nh y khoa hoc t vn y t khng lin quan n iu tr m au hoc thng
tt, bao gm c kim tra ph khoa/nam khoa; Xt nghim nh k, khm nh k cho tr mi sinh, tt c cc hnh thc tim chng, vcxin v thuc phng nga (tr trng hp tim vc-xin sau khi b tai nn hay sc vt, cn trng cn); Khm v xt nghim khng c kt
lun bnh ca bc s.

12. Kim tra th lc, thnh gic thng thng, iu tr suy bin t nhin/khng phi v l do bnh l ca cho vic suy gim thnh th lc, bao
gm nhng khng gii hn cho cc tt khc x nh cn th, vin th v lon th v bt k phu thut phc hi hiu chnh no i vi
cc khuyt tt thoi ha thnh gic v th gic;

Sn phm ca Tng Cng ty Bo him Bo Vit

13. Phu thut chnh hnh, iu tr phc hi chc nng, chi ph cung cp, bo dng, sa cha hay thay th thit b y t h tr iu tr hay
b phn gi nh nh ngha. Tuy nhin ring phn s dng a m, np vis c nh vo c th c p dng gii hn 10% STBH ca
chi ph nm vin/phu thut i vi cc trng hp tai nn;
14. Gii phu thm m hoc phu thut to hnh tr khi vic gii phu ny nhm ti to li c quan b thng tt do tai nn trong thi hn
bo him ghi trong Giy chng nhn bo him, n bo him. Cc iu tr mang tnh cht thm m bao gm nhng khng gii hn
vic iu tr tng sc t (nm da), iu tr mn trng c, iu tr chng rng tc..b loi tr ring i vi iu kin ngoi tr. Trng hp
ngi c bo him b bnh ny phi iu tr ni tr th vn c gii quyt theo quyn li Chi ph y t do m au, bnh tt, tai nn;
15. Ph thai do cc nguyn nhn tm l hay x hi v cc hu qu hay bin chng ca cc iu tr trn; iu tr v sinh, th tinh nhn to,
iu tr bt lc, hoc thay i gii tnh v bt k hu qu hay bin chng no t nhng iu tr trn;
16. Xt nghim hoc cha tr lin quan n trit sn, nh sn, trnh thai hay ri lon chc nng sinh dc;
17. Cc cht b sung hoc thay th phc v cho vic n king c sn trong t nhin v c th c mua m khng cn ch nh, bao gm
nhng khng gii hn vi cc loi vitamin, khong cht v cc cht hu c (tr trng hp cc loi vitamin c ch nh dng chung
vi thuc iu tr v chi ph cho cc loi thuc ny khng ln hn chi ph thuc iu tr), m phm v dc m phm;
18. Hnh ng c ca Ngi c bo him hoc Ngi th hng quyn li bo him k c trong tnh trng tnh to hoc mt tr, lm
dng ru, lm dng hay nghin nhng thuc kch thch;
19. Ngi c bo him vi phm nghim trng php lut phi th n hnh s hoc vi phm lut l an ton giao thng nh ua xe, iu khin
xe khi c nng cn trong mu vt qu mc quy nh ca lut an ton giao thng ng b. Ngi c bo him b nh hng bi
ru, bia hoc cc cht kch thch khc l nguyn nhn dn n tai nn.
20. Ngi c bo him nh nhau, tr phi chng minh c l hnh ng t v;
21. Tham gia tp luyn hoc tham gia thi u cc mn th thao chuyn nghip, cc hot ng gii tr hoc mn thi u mang tnh cht nguy
him, iu khin hay tham gia vo bt k cuc ua xe, bt k hot ng di nc, thu qun, qun i hoc lc lng khng qun tr
phi c chp thun bng vn bn ca Bo Vit v ph bo him b sung c thanh ton;
22. Cc hot ng hng khng tr khi l hnh khch i trn trn my bay thuc Hng hng khng c giy php hp php kinh doanh chuyn
ch hnh khch;
23. iu tr hoc phu thut theo yu cu ca Ngi c bo him m khng phi iu tr theo cch thng thng;
24. iu tr ti phng mch bc s t, phng nha t nhn khng c giy php hnh ngh v khng cung cp c chng t/ha n ti chnh
theo quy nh ca lut php tr trng hp c quy nh khc c ghi r trong Bng tm tt hp ng bo him hoc Sa i b sung;
25. Dch v hoc iu tr ti nh, hoc ti cc Trung tm iu tr bng thu lc, spa, trung tm iu dng, an dng, bnh x hoc trung
tm chm sc di hn m khng c coi l mt bnh vin theo nh nh ngha;
26. iu tr nhng nc khng thuc phm vi lnh th ca Chng trnh;
27. Cc dch v iu tr min ph ti bt k bnh vin no;
28. Vic iu tr khng c khoa hc cng nhn;
29. iu tr y t hoc s dng thuc khng c s ch dn ca bc s;
30. Tt c cc chi ph lin quan n vic lm th tc xin th thc xut nhp cnh v/hoc h chiu;
31. Chi ph y t lin quan ti cng Thng tt, m au, bnh tt c th c bi thng t nhng loi hnh bo him khc. Trong trng hp
, Bo Vit ch thanh ton khon tin vt qu mc c bi thng theo cc n bo him khc hoc gii hn trch nhim trong
Bng quyn li bo him thuc n bo him ny, s tin no nh hn s c p dng;
32. Cc chi ph pht sinh do hu qu ca tai nn c sn xy ra trc thi gian tham gia bo him hoc ngoi thi hn bo him;
33. Cc chi ph trc tip hoc gin tip pht sinh t hoc yu cu t hu qu ca: chin tranh, bo ng, s xm lc, hnh ng th ch
hoc hot ng hiu chin t cc th lc th ich bn ngoi (d c tuyn b hay khng), nh cng, ni chin, ni lon, khi ngha
khng b, cp chnh quyn, bo ng, dn bin, phin lon, cc hnh ng qun s hoc hnh ng ca bt k ngi cm u ca t
chc no nhm lt , e do chnh quyn, kim sot bng v lc, khng b hoc hnh ng bo lc;
34. Thng tt, tn tt do n ht nhn hoc nhim phng x ht nhn, cht aming gy ra;
35. Nhng chi ph pht sinh v/hoc t vong do nhng thm ha thin nhin, thin tai hay i dch gy ra.
PHN 4 - CC IU KHON CHUNG
1. Hiu lc Bo him v ti tc Hp ng
Hiu lc bo him s bt u t ngy ghi c th trong Bng tm tt iu kin bo him hay Giy chng nhn bo him. Tt c cc khon ph
s c thanh ton vo hoc trc ngy c hiu lc, ngy ti tc hay vo ngy n hn qui nh trong Bng tm tt iu kin bo him hoc

Sn phm ca Tng Cng ty Bo him Bo Vit

10

Giy chng nhn bo him. Nu vic thanh ton khng c thc hin th Hp ng bo him s b v hiu ngay t ngy u ca thi hn
bo him cha c thanh ton ph tr khi c quy nh no khc.
Ph bo him khi ti tc s tng ln nu Ngi c bo him thuc nhm tui mi (nh phn loi nhm tui trong Bng Ph bo him)
vo ngy ti tc.
Trong trng hp Hp ng ti tc lin tc, hiu lc bo him chm dt vo ngy n hn u tin sau ngy sinh nht th 65 ca Ngi
c bo him, tr khi c tha thun khc c Bo Vit chp nhn.
i vi quyn li chnh v tt c cc quyn li b sung, bo him c hiu lc sau thi gian ch di y k t ngy Ngi tham gia bo him
ng ph bo him y theo quy nh:
a)

30 ngy i vi trng hp m au, bnh tt;

b)

30 ngy i vi quyn li chm sc rng;

c)

12 thng i vi bnh c bit v bnh c sn;

d)

Hiu lc ngay i vi trng hp tai nn;

e)

90 ngy i vi trng hp sy thai hay ph thai do ch nh ca bc s, ct b bung trng, iu tr thai sn;

f)

270 ngy i vi trng hp sinh ;

g)

Cc hp ng ti tc lin tc mc nhin c hiu lc ngay sau khi ngi tham gia bo him ng ph cho thi gian tip theo.

Cn c trn lch s bi thng ca Ngi c bo him, vo thi im xem xt ti tc hp ng, Bo Vit c quyn t chi ti tc hp ng
hoc iu chnh ph bo him v cc iu kin, gii hn ph ca cc quyn li trong hp ng bo him.
2. Hy b hp ng
Nu Ngi c bo him hoc i din Ngi c bo him c bt k khiu ni no th hin gian ln hay khng trung thc hoc nu c
hnh vi gian di hoc c mu k trc li bo him v bt k phng din no nhm ly tin bo him th Hp ng bo him ny s b hu
b ngay lp tc v Ngi c bo him s mt ton b Quyn li bo him cng nh ph bo him.
Vi iu kin Ngi c bo him khng c khiu ni no pht sinh hoc c thanh ton bi thng cho Ngi c bo him trong
sut thi hn bo him, Ngi c bo him c th chm dt Hp ng bo him vo bt k thi im no bng mt thng bo bng vn
bn trc 30 ngy v phi hon tr tt c Giy chng nhn bo him v Th bo him cho Bo Vit. Khon hon ph cn li s c thanh
ton sau khi khu tr khon ph ca thi hn c bo him c tnh trn biu ph bo him ngn hn ca Bo Vit.
3. ng Bo him/ Bo him khc/ i ngi th ba
n bo him ny ch bi thng theo t l nu Ngi c bo him c bt k mt hp ng bo him chi ph y t no khc ang cn hiu
lc t bt k mt chng trnh bo him no khc cho cng mt Thng tt thn th, m au/bnh tt hay T vong c bo him theo qui
tc bo him ny.
Ngi c bo him phi thng bo cho Bo Vit trong bt k hon cnh no khi c th khiu ni Ngi th ba. Ngi c nhn quyn li
bo him theo ngh v bng chi ph ca Bo Vit cho php v y quyn cho Bo Vit thc hin cc bin php v hnh ng cn thit, hp
l truy i bi thng t ngi th ba m Bo Vit c quyn hng theo iu khon Th quyn i bi thng ca n bo him ny.
4. i tng c tham gia Bo him
tui ti a c bo him l 64 v 65 tui i vi trng hp ti tc.
Ngi c bo him c th l bn thn ngi yu cu bo him hoc ngi ph thuc ca ngi yu cu bo him.
Tr em di 18 tui phi tham gia bo him cng vi b v/hoc m, ch c tham gia c lp nu b/m ang c mt loi hnh bo him y
t cn hiu lc ca Bo Vit v chng trnh ca con phi tng ng hoc thp hn chng trnh b m tham gia i vi c quyn li
chnh v cc quyn li b sung.
Bo Vit khng nhn bo him v khng chu trch nhim i vi:
a) Nhng ngi ang mc bnh tm thn, thn kinh, bnh phong
b) Nhng ngi b thng tt vnh vin t 50% tr ln
c) Nhng ngi ang trong qu trnh iu tr bnh hoc thng tt, tr mt s trng hp c bit Bo Vit c th chp nhn bo him v
xem xt p dng hoc khng p dng loi tr vnh vin bnh/thng tt v cc bin chng lin quan.

Sn phm ca Tng Cng ty Bo him Bo Vit

11

5. Ngha v ca Ngi c bo him

a) Ngi tham gia bo him k khai trung thc y cc ni dung trong Giy yu cu bo him ca Bo Vit.
b) Trung thc trong vic k khai cc thng tin v cung cp cc chng c v ri ro c bo him.
Trng hp Ngi tham gia bo him, Ngi c bo him hoc Ngi th hng quyn li bo him khng trung thc trong vic thc
hin cc quy nh trong Quy tc bo him ny, Bo Vit c th t chi mt phn hoc ton b mc chi tr tin bo him.
6. Kim tra
Bo Vit c quyn thng qua cc chuyn vin y t kim tra tnh trng sc kho ca Ngi c bo him vo bt k lc no khi cn thit
trong sut thi gian khiu ni. Ngoi ra, Bo Vit c quyn yu cu khm nghim t thi trong trng hp cht nu vic khm nghim ny
khng tri vi Php lut v phong tc tp qun.
7. Sa i
n bo him ny c th c sa i v thay i ti bt k thi im no theo s tho thun bng vn bn gia Bo Vit v Ngi c bo
him. Tt c vic sa i trong Hp ng/n bo him ny s rng buc cc bn k t ngy sa i c hiu lc.
Tt c nhng thay i trong Hp ng/n bo him ny s khng c hiu lc nu khng c i din ca Bo Vit chp thun v cp sa i
b sung.
Thay i quyn li
Gii hn trch nhim ca cc quyn li khng th thay i trong sut thi hn Hp ng bo him. Nhng quyn li ny ch c th c thay
i vo ngy ti tc ca Hp ng bo him.
8. Biu ph Bo him ngn hn
Ph bo him ngn hn s l:
Thi hn bo him khng qu 1 tun
Thi hn bo him khng qu 1 thng
Thi hn bo him khng qu 2 thng
Thi hn bo him khng qu 3 thng
Thi hn bo him khng qu 4 thng
Thi hn bo him khng qu 6 thng
Thi hn bo him khng qu 8 thng
Thi hn bo him hn 8 thng

bng
bng
bng
bng
bng
bng
bng
bng

1/8 ph nm
1/4 ph nm
3/8 ph nm
1/2 ph nm
5/8 ph nm
3/4 ph nm
7/8 ph nm
100% ph nm

9. Li chnh t
Nhng li chnh t s khng lm mt hiu lc ca nhng Hp ng bo him ang c hiu lc v ngc li s khng pht huy hiu lc ca
nhng n bo him khng cn hiu lc.
10. Thng bo chuyn nhng
Bo Vit s khng b rng buc phi chp nhn hoc b nh hng bi bt k thng bo chuyn nhng, y thc, th chp hoc cc giao dch
khc lin quan n Hp ng bo him ny.
11. Th quyn i bi thng
Bng vic chp nhn bi thng theo n ny pht sinh t nguyn nhn m au, thng tt, iu tr y t, Ngi c bo him chp thun
th quyn cho Bo Vit i vi mi khiu ni, yu cu, kin tng, quyn li hay i bi hon t cc bn th ba hay t cc cng ty bo him
ti mc m n ny bi thng.
12. Trng ti
Bt k mu thun kin v chuyn mn y t no lin quan n phng php iu tr tai nn hoc m au c gii quyt bi hai (02) chuyn
gia y t do cc bn ch nh bng vn bn bi cc bn. Nu kin ca hai chuyn gia y t trn khng thng nht th s c gii quyt thng
qua mt (01) trng ti do hai chuyn gia y t ch nh bng vn bn ngay t ban u. Trng hp hai chuyn gia y t khng ng vi quan
im ho gii th quyt nh ca trng ti l kt lun cui cng v c tnh rng buc i vi tranh chp ny.

Sn phm ca Tng Cng ty Bo him Bo Vit

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13. Tin trnh t tng

Ngi c bo him c quyn khiu ni v vic tr tin bo him ca Bo him Bo Vit trong vng su (06) thng k t ngy nhn c
thng bo ca Bo him Bo Vit v bt c khiu ni no cng khng c vt qu ba (03) nm k t ngy xy ra s kin dn n khiu
ni.
Mi tranh chp pht sinh t Quy tc bo him ny m khng th gii quyt bng thng lng s c gii quyt to n ca Vit Nam v
theo lut php Vit Nam.
14. Kt thc quyn li bo him
Tt c cc quyn li bo him theo Hp ng bo him ny s chm dt hiu lc vo 12 gi m ca ngy cui cng ca thi hn bo him
hoc vo ngy chm dt hiu lc bo him ty theo thi im no n trc.
PHN 5 TH TC BI THNG
I. Nguyn tc chung
1. H s bi thng (p dng cho tt c quyn li chnh v quyn li b sung)
Khi yu cu bi thng, Ngi c bo him hoc ngi th hng quyn li bo him phi gi cho Bo Vit bn gc cc giy t sau y
bng Ting Vit hoc Ting Anh trong 60 ngy k t ngy Ngi c bo him ra vin, cht hoc k t ln khm c chn on cui cng
ca Bc s v bnh/thng tt:
a.
b.
c.

d.

e.
f.

Giy yu cu bi thng (theo mu ca Bo Vit).

Bin bn tai nn c xc nhn ca c quan, chnh quyn a phng hoc cng an ni Ngi c bo him b tai nn (trng hp
Ngi c bo him b tai nn nghim trng) hoc bn tng trnh tai nn trong cc trng hp tai nn khc.
Cc chng t y t: s khm bnh, phiu iu tr, giy ra vin, kt qu xt nghim, toa thuc, phiu phu thut (trng hp m, phu
thut) Trng hp khng cung cp c bn chnh, c th cung cp bn photo c xc nhn ca n v tham gia bo him hoc
xc nhn sao y ca Bo Vit. Trong mi trng hp, Bo Vit c quyn yu cu cung cp bn chnh kim tra;
Cc chng t ti chnh: ha n ti chnh, bin lai, phiu thu theo quy nh ca B ti chnh, Cc thu lin quan ti iu tr v phu
thut. Cc chng t phi c np bng bn gc v s thuc s hu ca Bo Vit sau khi khiu ni c gii quyt. Ha n
mua thuc phi c xut trong vng 30 ngy k t ngy k n thuc.
Giy chng t, xc nhn quyn tha k hp php (trng hp Ngi c bo him cht).
Nu bc s iu tr gii thiu Ngi c bo him ti mt bc s chuyn khoa khc th Ngi c bo him cn mang theo giy
gii thiu ch nh ca bc s.

Cc khon thanh ton bi thng s c tr cho Ngi c bo him hoc Ngi th hng quyn li ca Ngi c bo him.
2. Thi hn bi thng
Bo Vit c trch nhim gii quyt v chi tr tin bo him trong thi hn ti a 15 (mi lm) ngy lm vic k t ngy nhn c h s
yu cu bi thng y v hp l. i vi h s cn xc minh thng tin, Bo Vit s tin hnh xc minh trong vng 30 ngy lm vic k
t ngy nhn c h s yu cu bi thng. Ngi c bo him s nhn c thng bo yu cu b sung h s trong vng 03 ngy lm
vic hoc thng bo h s cn xc minh trong vng 05 09 ngy lm vic k t khi b phn bi thng ca Bo Vit nhn c h s.
3. Thng tin chung v chi tr bo him
Tt c cc chng t v ti liu m Bo Vit yu cu h tr cho vic chi tr bo him, s c cung cp min ph cho Bo Vit, trc khi bt
k vic chi tr bo him no c hon tt.
Trng hp thiu thng tin y t, Ngi c bo him phi c trch nhim b sung cc thng tin cho Bo Vit v Bo Vit khng phi
chu chi ph cho vic c thm thng tin .
II. Cc trng hp iu tr/bi thng
1. Trng hp bo lnh thanh ton
Trng hp ngi c bo him khm v iu tr ti cc bnh vin, phng khm trong h thng bo lnh thanh ton ca chng trnh,
Ngi c bo him cn thc hin nhng bc sau :

Xut trnh th MedicalCare v chng minh nhn dn hoc h chiu, giy khai sinh (nu l tr em) cho bnh vin, phng khm.
Kim tra giy yu cu bi thng m bnh vin, phng khm cung cp sau khi iu tr v k tn xc nhn vic iu tr ca Ngi
c bo him.
Thanh ton cc chi ph trong bnh vin khng thuc phm vi bo him hoc vt qu mc trch nhim bo him.

Sn phm ca Tng Cng ty Bo him Bo Vit

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2. Trng hp tr tin trc, bi thng sau:

Trng hp Ngi c bo him khm v iu tr ti cc c s y t hp php khng thuc h thng bo lnh thanh ton ca chng trnh,
Ngi c bo him phi thanh ton mi chi ph iu tr, sau gi h s cho Bo Vit thanh ton phn chi ph thuc phm vi bo him.

PHN 6 - PH LC : DANH SCH CC BNH NGH NGHIP

Nhm I: Cc bnh Phi v Ph qun

Bnh bi phi-Silic ngh nghip
Bnh bi phi Atbet (Aming)
Bnh bi phi bng
Bnh vim ph qun mn tnh ngh nghip
Bnh hen ph qun ngh nghip
Nhm II: Cc bnh nhim c ngh nghip
Bnh nhim c ch v cc hp cht ch
Bnh nhim c benzen v cc hp cht ng ng ca benzen
Bnh nhim c thu ngn v cc hp cht thu ngn
Bnh nhim c mangan v cc hp cht ca mangan
Bnh nhim c TNT (trinitro toluen)
Bnh nhim c asen v cc hp cht asen ngh nghip
Bnh nhim c Nicotin ngh nghip
Bnh nhim c ho cht tr su ngh nghip
Bnh nhim c carbonmonoxit ngh nghip
Nhm III: Cc bnh ngh nghip do yu t vt l
Bnh do tuyn quang X v cc cht phng x
Bnh ic do ting n (ic ngh nghip)
Bnh rung chuyn ngh nghip
Bnh gim p mn tnh ngh nghip
Nhm IV: Cc bnh da ngh nghip
Bnh sm da ngh nghip
Bnh lot da, lot vch ngn mi, vim da, chm tip xc
Bnh nt du ngh nghip
Bnh vim lot da, vim mng v xung quanh mng ngh nghip
Nhm V: Cc bnh nhim khun ngh nghip
Bnh lao ngh nghip
Bnh vim gan vi rut ngh nghip
Bnh do xon khun Leptospira ngh nghip

Sn phm ca Tng Cng ty Bo him Bo Vit

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