QUY TC BO HIM

BO AN KHANG
c ph chun km theo Cng vn s ..../BTC-QLBH ngy xx/11/2017
ca B Ti Chnh v ban hnh theo Quyt nh s xxxx/2017/...... ngy
xx/11/2017 ca Tng Gim c
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IU 1: CC IU KIN CHUNG
1. nh ngha: Nhng t ng sau y p dng cho ton b Quy tc bo him ny v c
hiu:
1.1. PTI l Tng Cng ty c phn Bo him Bu in v cc n v trc thuc Tng Cng
ty c phn Bo him Bu in.
1.2. Tai nn l mt s kin bt ng hay khng lng trc, gy ra bi mt lc t bn
ngoi, c th nhn thy c xy ra trong thi hn bo him v l nguyn nhn trc
tip dn n thng tt thn th hoc cht cho Ngi c bo him.
1.3. Ti khon l ti khon ngn hng, ti khon in thoi, v in t hay dng ti
khon thanh ton no khc m Bn mua bo him ch nh trong n yu cu
bo him v ph bo him ca Quy tc bo him ny s c thanh ton t ti
khon .
1.4. Chng trnh bo him l chng trnh c Ngi c bo him la chn
c ghi r trn Giy chng nhn bo him hoc Hp ng bo him.
1.5. Ngy hiu lc l ngy c tha thun trong Hp ng bo him v c ghi trn
Giy chng nhn bo him.
1.6. Nm vin l iu tr ni tr ti bnh vin trong thi gian qu hai mi bn (24) gi
lin tc theo ch nh ca bc s. Giy xut vin l chng t cn thit yu cu bi
thng cho quyn li ny.
1.7. Bnh vin l mt c s khm cha v iu tr bnh hp php c lut php Vit
Nam hoc nc s ti cng nhn l bnh vin. Hot ng chnh ca c s
khng phi l:
a. Vin tm thn, vin ch cha tr cn bnh v tm thn bao gm bnh vi nhng
triu chng bt thng, khoa tm thn ca mt bnh vin;
b. Bnh vin ng y hoc y hc c truyn;
c. Ni cho ngi gi, nh an dng, ni cho ngi nghin ru v nghin ma
ty;
d. Phng khm t nhn, phng khm cha tr thin nhin hoc bng nc, hoc
l mt c s chm sc m rng, phc hi chnh hnh;
e. Trm y t hoc trung tm y t d phng, trung tm y t huyn hoc x,
phng, phng y t cc cp huyn, x, phng.
1.8. Phng khm t nhn, phng khm cha tr thin nhin hoc bng nc l mt
hnh thc t chc ca c s khm bnh c cp php hp php, c t nhn
iu hnh v c qun l cng khai.
1.9. Trm y t l mt hnh thc t chc ca c s khm bnh c cp php hp php
v c chc nng cung cp, thc hin vic chun on, khm, cha bnh ban u
hoc tm thi i vi cc bnh nhn.
1.10. Hp ng bo him l s tha thun gia bn mua bo him v doanh nghip
bo him, theo bn mua bo him phi ng ph bo him, doanh nghip bo
him phi tr tin bo him cho ngi th hng hoc bi thng cho ngi c
bo him khi xy ra ri ro thuc phm vi bo him.
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Hp ng bo him tun th y cc ni dung quy nh ti Lut kinh doanh bo
him v ph hp vi quy nh ti iu 2 di y.
1.11. Ngi c bo him l ngi c tn trn giy chng nhn bo him. Ngi
c bo him c th l bn mua bo him hoc ng thi l ngi th hng ca
hp ng bo him. Ngi c bo him phi nm trong tui t nm (05) n
su mi lm (65) vo ngy hiu lc ca hp ng bo him. Trng hp tr em
di 18 tui tham gia bo him phi c xc nhn bi b hoc m tham gia
hp ng bo him.
1.12. Thng tt l tn thng thc th gy ra bi tai nn. Mt thng tt s ch c
coi l thng tt thn th nu n l hu qu u tin ca tai nn v khng phi l
mt chui s tch t ca tai nn hoc chn thng hoc gin tip gy ra bi s trm
trng thm do s suy yu th lc, khuyt tt, qu trnh thoi ha hoc bnh tt tn
ti trc khi bt u bo him theo quy tc bo him ny.
1.13. Bn mua bo him l ngi c yu cu bo him cho bn thn mnh v/ hoc cho
cc thnh vin khc v ngi ph thuc nu c yu cu v c PTI chp nhn
bo him. Bn mua bo him c th ng thi l Ngi c bo him hoc Ngi
th hng. Bn mua bo him phi c quyn li c th c bo him theo quy
nh php lut.
1.14. Ngy ti tc l ngy k nim hng nm ca Ngy hiu lc theo Hp ng bo
him c ti tc.
1.15. Thi hn bo him c tnh l mt nm dng lch tnh t ngy hiu lc. Hp
ng bo him s t ng ti tc vo Ngy ti tc.
1.16. Bc s l bc s c cp php hp php v hnh ngh trong phm vi giy php
hnh ngh quy nh theo php lut ti nc s ti. Bc s khng bao gm Ngi
c bo him, v hoc chng ca Ngi c bo him, cc con (con rut hay
con nui), anh ch em rut, anh ch em du r, cha m rut, cha m v/ chng, ng
b ni/ ngoi, chu ni/ ngoi, cha m k hoc con ring ca chng hoc v.
1.17. Phu Thut l mt phng php khoa hc iu tr thng tt hoc bnh tt
c thc hin bi v c giy chng nhn phu thut ca bc s phu thut c
bng cp thng qua nhng ca m vi cc dng c y t hoc bng thit b y t trong
bnh vin.
1.18. Bnh c bit l nhng bnh c bc s kt lun gm x gan bnh huyt p, tim
mch, lot d dy, vim a khp mn tnh, lot rut, vim gan, vim mng trong d
con, tr, si trong cc h thng tit niu v ng mt, c nhn mt, Parkinson,
bnh tiu ng, bnh lin quan n h thng ti to mu, iu tr ct Amidan,
phu thut dy chng, bnh Lupus ban , vim thn mn tnh v vim xoang mn
tnh.
1.19. Ngy thay i chng trnh bo him l ngy m PTI v Ngi c bo him
tha thun ng thay i chng trnh bo him.
1.20. D tt bm sinh l s pht trin bt thng v hnh dng, cu trc hoc v tr ca
cc b phn hoc cu trc c th, d dng tn ti ngay t giai on pht trin trong
t cung ca ngi m hoc l kt qu ca sinh non, cng nh nhng bt thng
v th cht tr s sinh, theo kin ca bc s.
1.21. Tnh trng bnh tt c sn l bnh tt hay thng tt c t trc ngy bt u
bo him ghi trn Hp ng bo him hoc sa i b sung v l bnh tt/ thng
tt m Ngi c bo him.
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a) phi iu tr trong vng 12 thng tnh t ngy bt u bo him.
b) Nhn bit triu chng bnh tt/ thng tt hoc nhn bit bnh tt/ thng
tt tn ti trc ngy bt u bo him cho d Ngi c bo him c
thc s khm, iu tr hay khng.
H s y t, tnh trng tin s bnh c lu gi ti cc c s y t hoc cc thng
tin do Ngi c bo him t k khai v/ hoc kt lun ca bc s c xem l
bng chng y v hp php v tnh trng bnh c sn.
1.22. Bn khai bo tnh trng sc khe: Thng tin v tnh trng sc khe ca Ngi
c bo him s c thng tin cho PTI cng vi giy yu cu bo him hoc
Hp ng bo him. Ni dung khai bo ny c th thc hin bng vn bn hoc
thng qua vic khai thc thng tin t nhn vin bn hng ca PTI.
1.23. Bnh ngh nghip l bnh pht sinh do iu kin lao ng c hi ca ngh nghip
tc ng ti ngi lao ng. Danh mc Bnh ngh nghip theo quy nh ca B y
t.
2. Tnh ton vn v cc thay i trong hp ng bo him
Quy tc bo him ny cng vi bng quyn li bo him, Giy chng nhn bo him v
cc iu khon sa i, b sung cu thnh Hp ng bo him. Vic thay i phi ph
hp vi quy tc, iu khon, biu ph c B Ti chnh ph chun v ghi nhn trong
Giy chng nhn bo him hoc trong iu khon sa i b sung trc khi cc thay
i ny c hiu lc.
3. Kim tra y t
Khi xt duyt yu cu tr tin bo him, PTI c quyn mi Bc s khm bnh li hoc
kim tra sc khe ca Ngi c bo him bng chi ph ca PTI.
4. Hn mc trch nhim
PTI s khng c trch nhim bi thng bt c khon no vt qu s tin bo him
c nu trong Giy chng nhn bo him v/ hoc iu khon sa i b sung ca
Hp ng bo him.
5. Gii hn a l
Gii hn a l bo him l phm vi ton cu ngoi tr c nhng qui nh hoc sa i
b sung khc trong Hp ng bo him/ Giy chng nhn bo him.
6. Ph bo him
Bn mua bo him c la chn cc hnh thc ng ph bo him theo k: hng ngy,
hng tun, hng thng, hng qu, na nm, nm c quy nh trong hp ng bo
him v ghi trn giy chng nhn bo him. Thi hn thanh ton ph bo him ca k
ng ph bo him u tin khng vt qu 30 ngy k t ngy bt u thi hn bo
him. Thi hn thanh ton ph ca cc k tip theo c thc hin theo tha thun v
ph hp vi quy nh php lut.
7. Hp ng ti tc
Hp ng bo him s c t ng ti tc thm mt nm tnh t Ngy ti tc, theo
cng iu khon iu kin v i tng bo him, tr trng hp bn mua bo him
v/hoc PTI c thng bo khc trc ngy ht hn ca thi hn bo him.
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Cc trng hp c php t chi ti tc bo him gm:
- C cung cp thng tin sai s tht nhm giao kt hp ng bo him c tr tin
bo him hoc c bi thng.
- Hp ng bo him nm lin k trc c t l bi thng trn 300%.
- Khng ng ph bo him theo thi hn thanh ton ph bo him.
8. Thay i chng trnh bo him tham gia
Trong thi hn bo him, bn mua bo him c quyn yu cu PTI thay i chng trnh
bo him ca Hp ng bo him theo tha thun trong n yu cu bo him. Mi s
thay i phi c phi c PTI xc nhn trc khi c hiu lc. Ph bo him iu
chnh bng khon chnh lch gia ph bo him ca chng trnh bo him mi v c
trn c s thi gian bo him cn li.Trng hp tng S tin bo him, thi gian ch
cho phn s tin bo him tng hn s p dng li t thi im thay i chng trnh.
9. Chm dt hp ng bo him
a. Ngoi cc trng hp chm dt Hp ng bo him theo quy nh ca php lut,
trng hp mt trong hai bn ngh chm dt Hp ng bo him, bn yu cu chm
dt phi thng bo bng cho bn kia trc 15 ngy. Thng bo chm dt c th c
thc hin bng vn bn, nhn tin hoc gi email. Trong trng hp ph bo him
c thanh ton trc nguyn nm, PTI s hon tr 80% ph bo him ca thi gian
hiu lc cn li trong vng 45 ngy k t ngy chm dt hp ng bo him vi iu
kin trong nm bo him , hp ng bo him ny cha c ln no c PTI chp
nhn tr tin bi thng.
b. Chm dt bo him
Hp ng bo him ny s chm dt trong nhng trng hp sau y:
- Ngi c bo him b c quan nh nc c thm quyn bt giam;
- Khi Ngi c bo him khng tiu chun l Ngi c bo him theo nh
ngha ti hp ng bo him ny;
- Khi Ngi c bo him b t vong;
- Khi Ph bo him khng c thanh ton y v ng thi hn thanh ton ph bo
him, Hp ng bo him s chm dt khi ht thi hn thanh ton ph bo him.
10. Thi gian ch
Thi gian ch l khong thi gian c tnh k t ngy hiu lc u tin ca thi hn
bo him, trong thi gian Ngi c bo him khng c chi tr tin bo him,
tr khi c quy nh khc i trong giy chng nhn bo him:
- Khng p dng thi gian ch i vi thng tt do tai nn v hp ng ti tc;
- Ba mi (30) ngy i vi bnh khng phi bnh c bit;
- Chn mi (90) ngy i vi cc tnh trng bnh c sn;
- Ba trm su lm (365) ngy i vi bnh c bit.
11. Lut p dng v gii quyt tranh chp
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a. Quy tc bo him ny s c iu chnh v din gii theo php lut Vit Nam.
b. Nu c bt k tranh chp no pht sinh t/ hoc lin quan n Hp ng bo him,
s c gii quyt bng thng lng gia Bn mua bo him v PTI.
c. Trong trng hp bn mua bo him v PTI khng th gii quyt tranh chp c
bng thng lng trong vng ba mi (30) ngy k t ngy xy ra tranh chp, bn
no cng c quyn a v tranh chp ra ta n c thm quyn ti Vit Nam gii
quyt. Phn quyt ca ta n l quyt nh cui cng, c gi tr rng buc v phi thi
hnh i vi c hai bn.
d. Thi hiu khi kin l ba (3) nm k t ngy pht sinh tranh chp.
12. Ngha v khai bo
Vic khai bo ca bn mua bo him/ Ngi c bo him v cc cam kt, k khai yu
cu bo him l c s ca quyt nh ng cp Giy chng nhn bo him, v l mt
phn khng tch ri ca Hp ng bo him. PTI c quyn n phng nh ch thc
hin Hp ng bo him v thu ph bo him n thi im nh ch thc hin Hp ng
bo him khi bn mua bo him c mt trong nhng hnh vi sau y:
a. C cung cp thng tin sai s tht nhm giao kt Hp ng bo him c tr
tin bo him hoc c bi thng;
b. Khng thc hin cc ngha v trong vic cung cp thng tin cho PTI theo quy nh ti
Lut kinh doanh bo him.

IU 2: QUYN LI BO HIM
Phm vi bo him ny bao gm cc bnh hoc thng tt i vi Ngi c bo him do
nguyn nhn tai nn v/ hoc bnh gy ra trong thi hn bo him. PTI c trch nhim gii
quyt bi thng bo him i vi cc quyn li bo him tng ng mc trch nhim bo
him nu ti giy chng nhn bo him gm:
1. Tr cp vin ph hng ngy
PTI s chi tr s tin bo him tr cp cho mi ngy nm vin trong trng hp Ngi
c bo him nm vin ni tr t hai ngy tr ln. S tin bo him tr cp cho mi
ngy cn c theo chng trnh bo him ang c hiu lc ti ngy nm vin u tin.
S ngy chi tr quyn li bo him ny c tnh t ngy nm vin th hai tr i, khng
tnh cho ngy nm vin u tin. Tng s ngy chi tr quyn li bo him ti a c
xc nh khng vt qu 20 ngy trong mt ln nm vin v khng vt qu 50 ngy
trong mt nm bo him.
2. Tr cp phu thut
PTI s chi tr mt ln duy nht s tin bo him tr cp phu thut theo chng trnh
bo him ang c hiu lc nu Ngi c bo him c iu tr phu thut ni tr
do bnh tt hoc tai nn. Ca phu thut i vi nguyn nhn tai nn phi xy ra trong
vng ba mi (30) ngy k t ngy xy ra v tai nn.
3. T vong trong thi gian nm vin iu tr thng tt do nguyn nhn tai nn
PTI s chi tr mt ln duy nht s tin bo him tr cp t vong theo chng trnh bo
him ang c hiu lc nu Ngi c bo him b t vong trong thi gian nm vin
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iu tr ni tr do nguyn nhn tai nn. Vic t vong do nguyn nhn tai nn phi xy
ra trong vng ba mi (30) ngy k t ngy pht sinh v tai nn.

IU 3: IU KHON LOI TR TRCH NHIM BO HIM

1. PTI khng thanh ton bi thng cho cc hng mc iu tr bnh tt/ thng
tt sau:
1.1. Chm sc nha khoa, iu tr ty, ng chn rng, thay rng hoc lm hm rng gi
mi;
1.2. Dng thai, sinh con, bin chng thai sn v cc iu tr lin quan n thaisn;
1.3. iu tr ri lon tm thn, ng kinh, cc bnh v thn kinh, ri lon hnh vi,
nghin ru, nghin ma ty;
1.4. Bnh tt bm sinh, cc d tt, bnh do bin i gen hoc cc ch nh phu thut c
t trc ngy bt u bo him;
1.5. Thoi ha cc loi khp, thot v a khp, thot v a m, bn trt khp hoc
trt t sng, thoi ha hoc tiu t sng, ngoi tr trng hp b gy xng
hoc trt ct sng do tai nn; phu thut dy chng hoc ni gn;
1.6. Cc iu tr trn ngi b nhim vi rt suy gim min dch ngi (HIV), hi chng
suy gim min dch mc phi (AIDS), bnh hoa liu hoc cc bnh ly qua ng
tnh dc khc, bnh ngh nghip, bnh lao, bnh st rt v cc bin chng do hu
qu ca vic iu tr trn;
1.7. Cc kim tra sc khe hoc khm gim nh y khoa m khng lin quan n vic
iu tr bnh tt;
1.8. Phu thut thm m, chnh hnh phc hi chc nng, vt l tr liu; lm gi cc b
phn ca c th;
1.9. Cc th thut hoc tiu phu cn c theo h s bnh n ti bnh vin;
1.10. Nhng thng tt vnh vin trn 50% c t trc khi tham gia bo him;
1.11. Cc bnh phong, cc bnh ung th, u cc loi, suy ty xng, hen suyn;
1.12. Ngi c bo hm iu tr y t hoc s dng thuc khng theo ch dn ca bc
s hoc c quan y t, iu tr khng c khoa hc cng nhn; iu tr mang tnh
th nghim.

2. PTI khng thanh ton bi thng cho bt c bnh tt/ thng tt pht sinh t
hoc l hu qu ca mt trong nhng nguyn nhn sau:
2.1. Ngi c bo him hnh ng di tc ng ca thc ung c cn, thuc kch
thch, ma ty, trng hp xt nghim thy trong mu c nng cn cao hn mc
phn trm ti a c php i vi tng trng hp tng ng theo lut php ca
nc s ti;
2.2. T t hoc t mnh gy thng tt;
2.3. ng t, ni la, nhim phng x, chin tranh, nh cng, ni chin;
2.4. Cc ri ro mang tnh i dch theo cng b ca c quan c thm quyn;
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2.5. iu tr, phu thut hiu chnh i vi cc khuyt tt thoi ha thnh gic v th
gic, v cc tt khc x ca mt (bao gm: cn th, lon th, vin th, lc), mi mt
iu tit, c thy tinh th (c nhn mt, cm);

2.6. Cm t ngt, trng gi, nhng tai bin trong qu trnh iu tr bnh;
2.7. Ng c thc n hoc ht phi hi c, cht c.

3. PTI khng thanh ton bi thng cho bnh tt/ thng tt xy ra do nguyn
nhn trc tip sau:
3.1. Hnh ng c ca Ngi c bo him tr trng hp Ngi c bo him
c hnh ng cu ngi, cu ti sn ca nh nc, ca nhn dn v tham gia
chng cc hnh ng phm php;
3.2. Trong khi Ngi c bo him tham gia luyn tp hoc thi u cc mn th thao
chuyn nghip, sn bn th vt, bt k hot ng ua no, ln khoang hoc du
hnh trong khinh kh cu, li tu ln, nhy bungee (nhy trn khng trung chn ct
vo si dy), leo ni vi dng c, hoc ln vi bnh oxy v thit b th di nc;
3.3. Trong khi Ngi c bo him ln khoang hoc di chuyn bng my bay khng
c giy php chuyn ch hnh khch hoc khng ng k hot ng dn dng;

3.4. Trong khi Ngi c bo him iu khin hoc lm vic vi t cch thnh vin phi
hnh on trn my bay hay trn tu thy;

3.5. Trong khi Ngi c bo him tham gia nh nhau tr khi c xc nhn l
hnh ng t v;
3.6. Trong khi Ngi c bo him thc hin hnh vi vi phm quy nh php lut ca
nc s ti, quy nh, quy ch ca bt k t chc no, hoc trong khi Ngi c
bo him b bt, b giam, hoc ang b trn lnh bt giam;

IU 4: GII QUYT BI THNG

1. Thng bo tn tht
Trong vng mi lm (15) ngy k t ngy kt thc t iu tr, bn mua bo him hoc
Ngi c bo him hoc Ngi i din theo php lut ca h, ty tng trng hp,
phi nhanh chng thng bo cho PTI bng in thoi/ email/ th bu in/ vn bn.
2. Chng c v tn tht
Khi yu cu bi thng, Bn mua bo him hoc Ngi c bo him hoc Ngi i
din theo php lut ca h, bng chi ph ca ring mnh, phi cung cp cho PTI y
chng c cn thit theo lit k ti mc 4 iu 4 di y.
3. Thi hn yu cu tr tin bo him
Thi hn yu cu tr tin bo him theo hp ng bo him l mt nm, k t ngy xy
ra s kin bo him. Thi gian xy ra s kin bt kh khng hoc tr ngi khch quan
khc khng tnh vo thi hn yu cu tr tin bo him.
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4. H s yu cu bi thng
Khi yu cu PTI thanh ton quyn li bo him, Ngi c bo him bng chi ph ca
mnh, phi gi cho PTI cc chng t sau y:
- Giy yu cu tr tin bo him theo mu ca PTI;
- Bn sao th cn cc cng dn hoc giy chng minh nhn dn hoc h chiu hoc
chng thc c nhn hp php khc, giy chng nhn bo him/ hp ng bo him
hoc sa i b sung;
- Giy xut vin, ha n/ bin lai thu tin vin ph v bng k chi ph nm vin ni
tr c xc nhn ng du ca bnh vin;
- Giy chng nhn phu thut (trng hp phu thut);
- Bin bn tai nn giao thng (trng hp tai nn giao thng) hoc bin bn tai nn
c xc nhn ca cng an a phng ni Ngi c bo him b tai nn hoc Bin bn
tai nn lao ng (trng hp tai nn lao ng)
- Giy chng t c xc nhn t vong ti bnh vin (trng hp Ngi c bo
him cht);
- Chng t chng minh quyn tha k hp php;
- Cc giy t lin quan n vic gii quyt bi thng bo him (nu c).

5. Thanh ton bi thng.

PTI c trch nhim xem xt, gii quyt v thanh ton cho Ngi c bo him trong
thi gian quy nh di y.
PTI s thanh ton tin bi thng trong vng mi lm (15) ngy lm vic sau khi nhn
h s bi thng y v hp l; khng qu ba mi (30) ngy lm vic trong trng
hp PTI phi xc minh h s.