Secondary and Tertiary Care

Below are some reimbursement examples under the University’s medical insurance model. Please note that the examples are for reference only. All claims are subject to case-by-case review and governed by applicable terms.

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Case A – Assuming SMBS, Catastrophic Insurance and Top-up Medical Insurance are utilized for the same disability in the same year

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First Claim ($250,000)

Step 1: Initial Claim Submission

Total Eligible Expenses: $250,000

UHS identifies this as a potential Catastrophic Insurance case and sends the case to External Insurer.

Step 2: Reimbursement under Catastrophic Insurance

Under Catastrophic Insurance, a deductible of $100,000 applies. The external insurer can reimburse at most $135,000 after offsetting the deductible and applying the 90% reimbursement rate.

Item	Amount
Total Eligible Expenses	$250,000
Annual Deductible (per disability per contract year)	-$100,000
Amount Considered for Reimbursement	$150,000
Amount Reimbursed under Catastrophic Insurance (subject to max limit of each benefit item and the 90% reimbursement %)	$95,000
Remaining Expenses after Catastrophic Insurance coverage	$155,000 (=$250,000 – $95,000)

Step 3: Reimbursement under SMBS

UHS will reimburse remaining eligible expenses.

Item	Amount
Amount Reimbursed under SMBS (subject to max limit of each benefit item)	$100,000
Remaining Expenses after SMBS coverage	$55,000 (=$155,000 – $100,000)

If any balance remains and one has purchased Top-up Medical Insurance, UHS will pass the case to External Insurer. Otherwise, the outstanding amount will be borne by staff. Staff may also submit claims to their personal insurance policies, if any. 

Step 4: Reimbursement under Top-up Medical Insurance

If one has purchased Top-up Medical Insurance, further reimbursement may be available.

Item	Amount
Remaining Expenses after SMBS	$55,000
Top-up Annual Deductible (e.g. Plan 1)	-$7,500
Top-up Eligible Amount (subject to max limit of each benefit item)	$47,500

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Second Claim ($80,000)

Step 1: Claim Submission

Total Eligible Expenses: $80,000

Since the annual deductible of $100,000 was already applied in the first claim, the full amount is now eligible for reimbursement by the External Insurer.

Step 2: Reimbursement under Catastrophic Insurance

Item	Amount
Total Eligible Expenses	$80,000
Annual Deductible (per disability per contract year)	$0
Amount Considered for Reimbursement	$80,000
Amount Reimbursed under Catastrophic Plan (subject to max limit of each benefit item and the 90% reimbursement %)	$72,000
Remaining Expenses after Catastrophic Insurance coverage	$8,000 (=$80,000 – $72,000)

Step 3: Reimbursement under SMBS

UHS will reimburse eligible remaining expenses.

Item	Amount
Remaining Expenses after SMBS	$8,000
Amount Reimbursed under SMBS (subject to max limit of each benefit item)	$6,000
Remaining Expenses after SMBS coverage	$2,000

If any balance remains and one has purchased Top-up Medical Insurance, UHS will pass the case to External Insurer. Otherwise, the outstanding amount will be borne by staff. Staff may also submit claims to their personal insurance policies, if any. 

Step 4: Reimbursement under Top-up Medical Insurance

Item	Amount
Remaining Expenses after SMBS	$2,000
Top-up Deductible Already Applied (from first claim)	$0
Top-up Eligible Reimbursement Amount (subject to max limit of each benefit item)	$2,000

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Case B – Assuming SMBS and Top-up Medical Insurance are utilized for the same disability in a year

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Total Eligible Expenses ($60,000)

Step 1: Reimbursement under SMBS

UHS will reimburse eligible expenses accordingly.

Item	Amount
Amount Reimbursed under SMBS (subject to max limit of each benefit item)	$50,000
Remaining Expenses after SMBS coverage	$10,000

If any balance remains and one has purchased Top-up Medical Insurance, UHS will pass the case to External Insurer. Otherwise, the outstanding amount will be borne by staff. Staff may also submit claims to their personal insurance policies, if any. 

Step 2: Reimbursement under Top-up Medical Insurance

If one has purchased Top-up Medical Insurance, further reimbursement may be available.

Item	Amount
Remaining Expenses after SMBS	$10,000
Top-up Annual Deductible (e.g. Plan 2)	-$3,750
Top-up Eligible Reimbursement Amount (subject to max limit of each benefit item)	$6,250