Individual Health and Accident Insurance Policy Happy Health Plus 15,000

Key Benefits

1

Lum sump healthcare up to THB 300,000 with premium only 15,000 THB per person*

*Health packages and coverages depend on the insured age

2

Premiums can be used for personal income tax deduction

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Compare our plans in details, you'll definitely find something that suits you

Benefit Schedule

(Currency : Thai Baht)

Plan 1

Plan 2

Plan 3

Plan 4

Coverage


Entry age condition	18 – 30 years old	31 – 45 years old	46 – 55 years old	56 - 65 years old
Overall maximum limit per year	THB 300,000	THB 300,000	THB 300,000	THB 300,000
Maximum limit per confinement¹	THB 300,000	THB 300,000	THB 300,000	THB 300,000
Area of overage	Thailand only	Thailand only	Thailand only	Thailand only

1. Inpatient Benefits


Article 1 Room charge, meal fee and hospital service fee (Inpatient) per confinement
1.1 Non-Intensive Care Unit (maximum limit per day)	THB 4,000	THB 4,000	THB 3,000	THB 2,500
1.2 Intensive Care Inpatient Room, Coronary Care Unit (CCU)	THB 8,000	THB 8,000	THB 6,000	THB 5,000
Article 2 Medical fee for examination or treatment, blood and blood component service fee, nurse service fee, medicine fee, parenteral nutrition fee, and medical supplies fee per confinement.	THB 60,000	THB 60,000	THB 50,000	THB 50,000
2.1 Medical fee for examination
2.2 Medical fee for treatment, blood and blood component service fee, and nurse service fee
2.3 Medicine fee, parenteral nutrition fee and medical supplies fee
2.4 Medicine fee and disposable supplies fee (Medical Supplies 1) for home medication
Article 3 Physician’s examination fee (Physician) (maximum limit per day and up to Maximum limit per confinement¹	THB 6,000	THB 6,000	THB 6,000	THB 6,000
Article 4 Operation (surgery) and procedure fee (maximum limit per confinement)	THB 60,000	THB 60,000	THB 50,000	THB 50,000
4.1 Operating room fee and procedure room fee
4.2 Medicine fee, parenteral nutrition fee, medical supplies fee, and surgery and procedure fee
4.3 Physician’s fee for Physicians performing surgery and procedure (including assistant) (Physician fee)
4.4 Physician’s fee for anesthetist (Physician fee)
4.5 Medical fee for organ transplantation e.g. liver, pancreas, kidney, heart, lung, and bone marrow transplantation
Article 5 Day surgery (maximum limit per confinement)	Customary and Reasonable Medical Charges but up to Maximum limit under Article 2

2. Non-Inpatient Benefits


Article 6 Medical fee for related direct examination before and after hospitalization as an Inpatient or Outpatient treatment fee which is in consequence of or in connection with hospitalization as an Inpatient (maximum limit per confinement).
6.1 Medical fee for related direct examination which occurs within 30 days before hospitalization as an Inpatient and 60 days after hospitalization as an Inpatient.	No coverage
6.2 Outpatient Treatment fee after hospitalization as an Inpatient for each consequential treatment within 30 days after such discharge from the hospital (excluding medical fee for examination)	Customary and Reasonable Medical Charges but up to Maximum limit under Article 2
Article 7 Medical fee for Treatment of injury in Outpatient case within 24 hours after each accident	THB 10,000	THB 10,000	THB 5,000	THB 5,000
Article 8 Rehabilitation, Physical Therapy treatment fee after each hospitalization as an Inpatient within 30 days	Customary and Reasonable Medical Charges but up to Maximum limit under Article 2
Article 9 Medical fee for Treatment of chronic kidney failure by hemodialysis through vascular access for each policy period (maximum limit per year)	THB 60,000	THB 60,000	THB 50,000	THB 50,000
Article 10 Medical fee for Treatment of tumor or cancer by radiotherapy, interventional radiology, and nuclear medicine for each policy period (maximum limit per year)	Customary and Reasonable Medical Charges but up to Maximum limit under Article 2
Article 11 Medical fee for Treatment of cancer by chemotherapy for each policy period (maximum limit per year)	Customary and Reasonable Medical Charges but up to Maximum limit under Article 2
Article 12 Ambulance fee (maximum limit per confinement)	THB 1,000	THB 1,000	THB 1,000	THB 1,000
Article 13 Medical fee for Mini Surgery (maximum limit per confinement)	Customary and Reasonable Medical Charges but up to Maximum limit under Article 2

3.Additional Benefit


Loss of Life, Dismemberment, Loss of Sight or Permanent Disability (PA1) by an accident including Assault & Murder, and motorcycle accident as a riding or a passenger	THB 10,000	THB 100,000	THB 100,000	THB 100,000
Consultation Fees, Medicines, Drugs Prescribed by a Registered Physician, Laboratory Tests (1 Visit / Day, 30 Visits / Year)	THB 1,500	THB 1,500	THB 500	No coverage

Remarks:

¹Per confinement means Hospitalization as an Inpatient or treatment by day surgery at the Hospital (or “Health Facility”) each time and shall include hospitalization as an Inpatient or day surgery at the Hospital or Health Facility any times due to the same Injury or Illness which is not fully recovered including related or consequential complications within 90 days from the date of the latest discharge from the Hospital or Health Facility which shall be deemed as the same hospitalization.
Cover actual medical expenses according to benefit schedule as Customary and Reasonable Medical Charges but up to Maximum limit per confinement¹
Medical Necessity means the necessity to use medical services or other services of the Health Facility for examination or treatment of Injury or Illness which shall be subject to the following conditions:

(1) the services must be consistent with the diagnosis and treatment according to the symptoms of the Injury or Illness in a treated person.

(2) there is a clear medical indication in accordance with the standards of modern medical practice.
(3) the services are not solely for the convenience of the Covered Person or the Covered Person's family or the medical service provider.
The total maximum number of days for standard daily room including ICU and Coronary Care Unit (CCU) room is 365 Days.
Cost of outpatient emergency treatment due to injury within 24 hours of the injury or accident occurring including 15 days follow up. The Company will pay this benefit according to the amount actually paid but not exceeding the maximum amount per disability or the maximum benefit stated in the schedule whichever is smaller.
The company reserves the right to cover for lab tests, x-rays, diagnostics & pathology test, MRI, PET & CT scan on a case by case basis for customary and reasonable medical expenses subject to the maximum limit per disability
Any treatment outside Thailand, the company will pay benefits based on the exchange rate prevailing on the date specified in the medical bill. In the case of claims documents in foreign languages (Non-English language), the claims documents must be translated into Thai or English language by government department or an accredited translation institute and is considered as the cost of the Insured for translation and to submit the claim documents to the Company.
This insurance plan covers any hospital treatment outside the territory of Thailand. However, the duration of travel outside Thailand in each trip must be consecutive and maximum of 45 days.
Benefits under Article 1 – 13 cover actual medical expenses as Customary and Reasonable Medical Charges but in total cover up to Maximum limit per confinement¹
The insured person shall pay the insurance premium. Payment of premiums through insurance agents or insurance brokers consider as the distribution services only.
Happy Health Plus plan is marketing name of Universal Plus policy.
This document is not part of the insurance contract.
The policy will not cover any loss, injury, damage or legal liability arising directly or indirectly in the sanctioned countries declared by the United Nation (UN) or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States of America.
The annual premium includes 0.4% stamp duty.

Notes

Waiting period

1. The Company will not pay any benefit for any Illness occurring during the 30 days from the first day of the commencement date of the Insurance Policy or

2. The Company will not pay any benefit for the following Illnesses which occurred in the period of 120 days from the first effective date of the Insurance Policy;

2.1 Tumors, cysts or all types of cancer

2.2 Hemorrhoids

2.3 All types of Hernia

2.4 Pterygium or Cataracts

2.5 Tonsillectomy or adenoidectomy

2.6 All types of Calculus

2.7 Varicose Veins

2.8 Endometriosis

3. There is 180 days waiting period for Funeral Benefits if the death caused by sickness.

Reimbursement conditions

Reimbursement condition will be applied for the following benefits in which the insured must pay for the medical expenses upfront and get the treatment done, and later submit all the original bills together with medical certificate to reimburse with company after claims.

Medical fee for related direct examination which occurs within 30 days before hospitalization as an Inpatient and 60 days after hospitalization as an Inpatient.

Eligibility - Applicants must satisfy the following:

The applicants age must between 18 years old to 65 years old.
The applicant must be Thai resident or reside in Thailand at least 6 months in 12 months period.
All applicants must complete an application form and medical questionnaire. In some cases, we may request additional information.
Insurance policy will be effective after LMG approves the insurance application
The company reserves the right to adjust the coverage of the insured according to the increasing age that appears in the Happy Health Plus brochure at the renewal year and the company does not have to inform the insured in advance for the change.
Insurance policy does not cover pre-existing conditions and/or any treatment that are not complete at the time the policy commences.

Insurance Terms and conditions for Renewal Year

Once your application is approved, your policy will be continued renewal up to age 70 years old.
The Company may adjust the coverages, premium for a Policy Year, to reflect the age ranges and claim records of the respective Covered Persons, according to the rates approved by the registrar. The Company will give prior written notice thereof to the Covered Persons
In the renewal years, the insurance policy can be renewed after underwritten and approved by LMG.
This plan’s benefits limit are offered on per policy year basis. At the renewal year, the benefits annual limit will be reset for the policy year.
For the renewal premium, please refer to the Renewal Notice Letter.
Rates are subject to change without prior notice.
The company reserves the right to adjust the coverage of the insured according to the increasing age that appears in the Happy Health Plus brochure at the renewal year and the company does not have to inform the insured in advance for the change

Major of General Exclusions

This insurance does not cover any expenses arising from Medical Treatment, or damage arising from an Injury or Illness (including any complication), symptom, or irregularity, caused by:

Chronic disease, injury or illness that has not been cured before the date of the insurance contract (including complications that may occur later) or can be clinically proven or certified that such disease or disorders has occurred before the Insurance contract date, Birth Defect or Congenital Anomalies and Abnormalities, chronic disease, injury or illness which occurred prior to the effective date of the policy (including complications or recurrence that may occur later), abnormal growth, developmental problems, genetic disorders, hernias in a child age under 16 years old, circumcision, surgical treatment for Scoliosis, surgical treatment for Deviate Nasal Septum.
Cosmetic related treatment, surgery for reconstruction, skin treatment, acne, blemish, freckles, dandruff, scaring, hair loss, underweight or overweight, surgery to fix or adjust body defects, elective surgery, cosmetic surgery, unless the surgery on the organ is to fix and return it to normal function(s) which were damaged by the accident that was covered by this Insurance Policy. Such surgery must not be performed on genitals or breast.
Normal pregnancy, prenatal postnatal complications, childbirth delivery or termination of pregnancy or any consequence of it, except as specified otherwise in the Covered Person’s plan in this Policy.
Acquired Immune Deficiency Syndrome caused by the Human Immuno-deficiency Virus (HIV) infection including opportunistic pathogenic infection, Malignant Neoplasm or infection or any illness that reveals an HIV (Human Immunodeficiency Virus) positive blood test. Opportunistic pathogenic infection is also including but not limited to Pneumocystis Carinii Pneumonia, Organism or Chronic Enteritis, Disseminated Viral/Fungi Infection, Malignant Neoplasm including but not limited to Kaposi’s Sarcoma, Central Nervous System Lymphoma and/or any severe diseases known that are caused by AIDS or sudden death, illness or disability. AIDS includes HIV, Encephalopathy (Dementia) , viral epidemics, Venereal disease and sexually transmitted diseases.
Treatment or usage of drugs or substances for anti-ageing or giving of replacement hormone during climacteric or menopause, or for any bodily change arising from any physiological or natural cause, corporal imbecility in a female or male, treatment of sexual disorder, gender confirmation or transgender surgery.
General Health Check-up, request to be admitted at a Hospital or Medical Center, request for a surgical treatment, rehabilitation or rest for recuperation or treatment by only resting methods, any investigations that are not relating directly to an admission to a Hospital, Medical Center or Clinic, investigations for any injury or illness, treatments or laboratory tests which are considered as non-medical necessity or non-medical standard.
Investigation and treatment for abnormal eyesight, corrective eye muscle surgery, LASIK, expenses for vision devices, treatment, investigation or surgery for all types of strabismus.
Dental treatments, surgery or prevention of periodontal disease (gum disease), dental or Jaw disease, bruxism, prosthetic dentistry, dentures, crowns, root canal therapy, filling, orthodontic treatment, scaling, tooth extraction, root implants with the exception of accidental injury to teeth whilst the insurance policy is in force but also excluding dentures, crowning, orthodontics, dental bridge, root canal treatment or root implants.
Treatments for alcoholism and complications, treatment of narcotic drug addiction, cigarettes, alcohol or psychoactive substances.
Diagnostic, investigations or treatments symptoms or disease relating to mental illnesses, psychiatric, stress, anxiety, psychotic state, abnormal behavior or characteristics, attention deficit disorder, autism, stress, including eating disorders or anxiety.
Any experimental treatment, examination or treatment for Obstructive Sleep Apnea, sleeping disorders or snoring.
Any inoculations and vaccinations excluding rabies vaccination after animal bite and tetanus vaccination after injury.
Any treatment that is not considered as modern medical treatment including alternative medical treatments.

Remarks:

The above terms and conditions are only part of the insurance policy. Please study the full details and exclusions in the insurance policy.
Benefits Details of coverage conditions and complete exclusions are stated in the insurance policy. The insured person should study and make understand the coverage details and conditions before deciding to purchase insurance.

Submission of the Proofs of Claim

The above proofs must be submitted within 30 days from the date of discharge from a Hospital or Health Facility, or the date of treatment at a clinic. The receipt must be an original. The Company will return the original receipt, bearing the certification of the amount paid, to the Covered Person for use in a claim for a shortfall amount from another insurer.

Claims process

Method 1 Through the hospital network provider (fax claim or outpatient credit)

Method 2 Direct billing to LMG

Submit the following documents:

A completed claim form download from LMG website or consult with your agency or broker.
A copy of your ID card
A copy of the first page of the Insured's bank passbook
A medical report stating your symptoms, diagnosis and treatment. For treatment of skin diseases, the name of the prescription is also required.
Original receipts containing breakdown of costs
Letter of Attorney for Disclosing Medical Report (company form)
Laboratory results / X-ray results / Computed tomography (CT scan) results / Magnetic resonance imaging (MRI) results / Biopsy results / Pathology results Picture Take / read X-ray film, CT, MRI (if any)
Medical report certified by specialist/eye examination (issued by an ophthalmologist) (if any).
A copy of the daily memorandum of the case that has been duly certified by the investigating officer (if any).
Other documents up on requested by the company.

Remarks:

In case the insured person or beneficiary is juvenile aged less than 12 years old sign by yourself. Required parent or the legal representative of the insured person or beneficiary to certify with.
In the case of signing by finger print, required at least 2 witnesses to certify.
We may not pay your claim if you're not able to provide an original receipt for your medical costs.

This insurance policy is underwritten by LMG Insurance Public Company Limited. The Company reserves the right to consider underwriting. | Please ensure you read carefully and understand the insurance coverages and conditions prior to making a decision. | This brochure is not an insurance contract. The coverages and benefits that the insured will receive depend on the definition, conditions and exclusions specified under the purchased insurance policy and coverage plan.