Now existing health issues will not stop your customer from getting Health Insurance cover

Reality check

Population of India is

138 crore

20.3%

affected by Diabetes

22.2%

affected by Hypertension

What is the opinion?

Don’t Worry.. We Have the

SOLUTION !!

USP

~ No Pre-policy medical check-up

~ Automatic recharge

~ Annual health check-up

~ Coverage for non-medical benefits with consumable/ companion benefit

~ Premium reduction option

Plan details

SUM INSURED (in Rs)	3 Lacs	5 Lacs		7/10 Lacs
IN-PATIENT HOSPITALIZATION	Up to Sum Insured
DAY CARE TREATMENT	Up to Sum Insured
ROOM RENT	Twin Sharing up to 1% Sum Insured per day		Twin Sharing	Single Private Room
ICU CHARGES	Up to 2% of SI per day		No Limit
PRE-HOSPITALIZATION & POST- HOSPITALIZATION	Up to 7.5% of payable hospitalization expenses		Up to 10% of payable hospitalization expenses
CONSUMABLE ALLOWANCE	Rs.750 daily, Max 7 Days		Rs.1000/- daily, Max 7 Days
COMPANION BENEFIT	Rs.10,000 if hospitalization exceeds 10 Days		Rs.15,000 if hospitalization exceeds 10 Days
AMBULANCE COVER	Up to Rs.1000 per hospitalization
DOMICILIARY HOSPITALIZATION	Up to 10% of Sum Insured
RECHARGE OF SUM INSURED	Up to 100% of Sum Insured
DIALYSIS COVER	Up to Rs.1000 per sitting. Maxi 24 Months
ANNUAL HEALTH CHECK-UP	Every Year

Note :

1. Insulin dependent customers to apply CARE FREEDOM with add-on benefit HEALTH CHECK+ ( Diabetic Health Check-up)

2. 7/10 Lacs Sum Insured available for customers with entry age >45 Years.

MINIMUM ENTRY AGE	Individual Plan 5 Years for Sum Insured 3/5 Lacs 46 Years for Sum Insured for 7/10 Lacs Family Floater Plan 91 days with atleast 1 insured member above 18 Years of Age for Sum Insured 3/5 Lacs 91 days with atleast 1 insured member above 46 Years of Age for Sum Insured 7/10 Lacs
MAXIMUM ENTRY AGE	Child :24 Years Adult : No Age limit
RENEWAL	Life Long
CO-PAYMENT	20% for all customers enrolling in the policy 30% for all customers enrolling in policy after attaining Age>=71 Years
INITIAL WAIT PERIOD	30 Days for all Illness except Accidental injury
NAMED AILMENT WAIT PERIOD	24 Months
PRE-EXISTING DISEASE WAIT PERIOD	24 Months

Note :

1. Customer can reduce the Co-payment from 30% to 20% provided

a. Customer is enrolled at Age <71 Years ( Age of the eldest member in Floater Policy or Age of member in case of Individual policy)

b. Change is applicable on Renewal at Age>70 Years

c. Customer pays extra premium for Co-payment reduction

2. Customers on Insulin need to apply the Policy with Health Check-up+ optional cover

3. Children on Insulin can be covered in Floater Policy only

Sub-limits(Applicable on per policy Year basis)

Sub-Limit	3 Lacs	5 Lacs	7/10 Lacs
Treatment of Cataract(Per Eye)	Up to Rs.20,000	Up to Rs.30,000	Up to Rs.30,000
Treatment of Total Knee Replacement (Per Knee)	Up to Rs. 80,000	Up to Rs. 1,00,000	Up to Rs.1,20,000
Treatment for each and every Ailment / Procedure mentioned below
Surgery for treatment of all types of Hernia	Up to Rs. 50,000	Up to Rs. 65,000	Up to Rs.80,000
Hysterectomy
Surgeries for Benign Prostate Hypertrophy (BPH)
Surgical treatment of stones of renal system
Treatment for each and every Ailment / Procedure mentioned below
Treatment of Cerebrovascular and Cardiovascular disorders	Up to Rs. 2,00,000	Up to Rs. 2,50,000	Up to Rs.3,00,000
Treatments/Surgeries for Cancer
Treatment of other renal complications and Disorders
Treatment for breakage of bones

Named ailments waiting period

Following diseases will be covered after 24 months of continuous coverage:

~ Cancer and cardiac ailments

~ Cataract

~ Dilatation and curettage

~ Fissure / Fistula in anus, hemorrhoids/ piles, pilonidal sinus, ulcers of gastro intestinal tract

~ Surgery of genitourinary system unless necessitated by malignancy

~ Kidney stone / Ureteric stone / Lithotripsy / Gall bladder Stone

~ Pancreatitis

~ All types of hernia, hydrocele

~ Myomectomy for fibroids

~ Procedures for retinal disorders

~ Varicose veins and varicose ulcers

Unique features

Consumable allowance

~ Fixed amount is payable for each completed 24 hours of hospitalization

~ Benefit is payable for maximum 7 days of Hospitalization.

~ No amount is payable for first 3 days of Hospitalization.

~ Benefit will be paid on per hospitalization basis and won’t reduce basic Sum Insured.

~ No additional expense bills are required to claim the benefit amount.

Example: Mr.Ghosh has a 5 lakhs SI CARE FREEDOM policy. He was hospitalised on 1/1/18 for dengue treatment & discharged on 08/1/18. His total stay was for 7 days. He will be paid Rs4,000 under Consumable allowance for 4 days. First 3 days hospitalisation are not counted for calculating the Consumable Allowance

Companion benefit

~ The companion benefit is a fixed lump sum amount payable in case single hospitalisation more than 10 days.

~ Companion Benefit is Payable only once in a Year

~ There is no requirement for submitting any bills.

~ Benefit does not reduce the policy Sum Insured.

Example: Mr. Ghosh had Purchased a policy of Rs.10 lakh 0n 1/1/2018. He was hospitalized for treatment on 1/3/2018 and was discharged on 12/3/18.He will be paid Rs.15000/- lump sum amount under companion benefit.

Recharge of Sum Insured

~ If, due to claims made, you ever run out of or exhaust your Sum Insured, we reinstate the entire Sum Insured of your policy for the remaining policy period.

~ The Recharge amount shall be utilized only after the Sum Insured has been completely exhausted in that Policy Year.

~ The Recharge shall be available only for all future Claims and not in relation to any illness or injury for which a Claim has already been admitted for that Insured Person during that Policy Year.

~ The Recharge will only be applied once during the Policy Year.

~ Any unutilized Recharge cannot be carried forward to subsequent policy year.

Recharge illustration

	Scenario 1	Scenario 2	Scenario 3
Sum Insured	10,00,000	10,00,000	10,00,000
Claim 1 filed	6,00,000	10,00,000	11,00,000
Claim 1 eligible	6,00,000	10,00,000	10,00,000
Balance Sum Insured	4,00,000	-	-
Recharge available	10,00,000	10,00,000	10,00,000
Claim 2 filed	5,00,000	10,00,000	8,00,000
Claim 2 eligible	5,00,000	10,00,000	8,00,000
Balance sum Insured	9,00,000	-	2,00,000

Dialysis cover

Cover the dialysis expenses incurred by insured for 24 months from date of first occurrence up to Rs 1,000 per sitting.

Policy renewal is Mandatory for claiming the benefit in subsequent years

POLICY START DATE	FIRST OCCURANCE OF DIALYSIS	DATE TILL WHICH CLAIM WILL BE PAID
1^ST Jan 2015	31^st May,2020	30^th May,2022
1^st Jan 2015	2^nd Dec 2014	Not Covered

Annual health check up

~ All insured adult members can avail one health check up per policy year irrespective of claim status

~ Available on cashless basis only at our network providers

~ Annual Health Check-up not available for Children below 18 years

List of tests that can be availed are

Add- on benefits of

Deductible

~ Reduce your premium by adding Rs.25,000 deductible in the Policy

~ Deductible is applicable on Per Policy Year Basis i.e You get claim after the exhaustion of the Deductible amount in a policy year

~ Deductible will be applicable in addition to Co-payment/Sub-limits applicable in the policy

Following discounts will be applicable on the premium

Sum Insured	Discount
3 Lacs	24%
5 Lacs	22%
7 Lacs	20.5%
10 Lacs	18.5%

Claim scenario

Scenario 1: Claim for Cancer Treatment

Description	Claim calculations for Customer Opting for Deductible Optional cover	Amount	Claim calculations for Customer not Opting for Deductible Optional cover	Amount
Policy Sum Insure		Rs.5,00,000		Rs.5,00,000
Premium Paid ( 2A; SI=5 Lacs;Age 41-45)		Rs.8,834		Rs.11,325
Premium Paid ( 2A;SI=5 Lacs; Age 61-65)		Rs.29546		Rs.37,902
Claim Filled for Cancer Treatment		Rs.4,00,000		Rs.4,00,000
Claim Amount left after adjusting Deductible - (A)	Claim Amount =Rs.4,00,000 Deductible =Rs25,000 Balance Amount = Claim Amount- Deductible Amount	Rs.3.75,000	Claim Amount =Rs.4,00,000 Deductible =Rs.0 Balance Amount = Claim Amount- Deductible Amount	Rs.4,00,000
Amount left after adjusting Co-payment – (B)	Amount (as per Calculation A)= Rs.3,75,000 Co-payment Amount = 20% of (A)= Rs.75,000 Balance Amount = A- Co-payment Amount	Rs.3,00,000	Amount (as per calculation A)= Rs.4,00,000 Co-payment Amount = 20% of (A)= Rs.80,000 Balance Amount = A- Co-payment Amount	Rs.3,20,000
Cancer Treatment Sublimit –(C)		Rs,2,50,000		Rs,2,50,000
Claim Amount Payable	Lower of Amount in C and B	Rs.2,50,000	Lower of Amount in C and B	Rs.2,50,000

Scenario 2: Claim for treatment of renal stone

Description	Claim calculations for Customer Opting for Deductible Optional cover	Amount	Claim calculations for Customer not Opting for Deductible Optional cover	Amount
Policy Sum Insure		Rs.5,00,000		Rs.5,00,000
Premium Paid ( 2A; SI=5 Lacs)		Rs.8,834		Rs.11,325
Premium Paid ( 2A;SI=5 Lacs; Age 61-65)		Rs.29546		Rs.37,902
Claim Filled for Cancer Treatment		Rs.1,00,000		Rs.1,00,000
Claim Amount left after adjusting Deductible - (A)	Claim Amount =Rs.1,00,000 Deductible =Rs25,000 Balance Amount = Claim Amount- Deductible Amount	Rs.75,000	Claim Amount =Rs.1,00,000 Deductible =Rs.0 Balance Amount = Claim Amount- Deductible Amount	Rs.1,00,000
Amount left after adjusting Co-payment – (B)	Amount (as per Calculation A)= Rs.75,000 Co-payment Amount = 20% of (A)= Rs.15,000 Balance Amount = A- Co-payment Amount	Rs.60,000	Amount (as per calculation A)= Rs.1,00,000 Co-payment Amount = 20% of (A)= Rs.20,000 Balance Amount = A- Co-payment Amount	Rs.80,000
Cancer Treatment Sublimit –(C)		Rs.65,000		Rs.65,000
Claim Amount Payable	Lower of Amount in C and B	Rs.60,000	Lower of Amount in C and B	Rs.65,000

Health check-up +

Customer can upgrade their policy Annual Health Check-up to Diabetes or Cardiac specific check-up by opting for this Optional Cover

List of Tests Covered

Home care

~ Covers expenses incurred towards hiring a qualified nurse under the recommendation of a treating medical practitioner.

~ Purpose of home care benefit is to provide care and convenience to customer to help him perform his necessary daily activities

~ We will pay up to 1000 per day subject to maximum of 7 days per illness/injury & maximum of 45 days per policy year

~ No amount is payable for first day (24 hours) per hospitalization.

Sourcing guidelines

Customers having standalone pre-existing conditions

~ Policies with customers having ANY of the following chronic conditions will be accepted

~ Hypertension

Acceptable provided hypertension has not resulted in complications like Heart, kidney failure, eye disorders

~ Diabetes Mellitus

Acceptable for all Type 1/Type 2 diabetes (with/without Insulin dependence) except for customer with complications like kidney failure, retinopathy, gangrene and foot ulcers etc

~ Standalone Obesity ( BMI<37)

~ Autism/Depression/Anxiety Disorder

~ Osteoarthritis/Thyroid

~ TB cured within 1 year

~ Pancreatitis or any acute infectious condition completely cured

Note : It is MANDATORY to opt for Diabetics Health Check-up+ in case any one or more Insured member are on Insulin

Customers having multiple pre-existing conditions

Policies with customers having Multiple (in any combination) Chronic conditions will be accepted

~ Diabetes Mellitus,

~ Hypertension,

~ Lipid Disorders (like high cholesterol),

~ Obesity (BMI <= 35)

Customers having special health conditions

Customers having below mentioned Special Medical conditions can approach the branch for more information

~ 5 Years after the cancer is cured

~ Rheumatoid arthritis cured

~ Brain Stroke

Proposals will Not be accepted for customers having :

~ Any type of Cancers

~ All Heart/Cardiovascular disorders

CABG, Angioplasty, Coronary Artery Disease, Heart Attack,

Valve disease and other diseases of the heart.

~ Disorders of Spinal Cord, Brain and Meninges

Stroke, Hemorrhage, Paralysis, Brain Tumor, Multiple

Sclerosis, Epilepsy etc.

~ Neuromuscular disorders

Motor Neuron Disease, Cerebral Palsy etc.

~ Chronic Lung Diseases

COPD (Chronic Obstructive Pulmonary Disease, ILD (Interstitial Lung Disease)

~ Chronic Liver Disease:

Hepatitis B/C, Cirrhosis, Liver Failure

Proposals will Not be accepted for customers having :

~ Pancreatitis except if cured already

~ Psychiatric and Mental Disorders except Autism / Anxiety /Depression

~ Chronic Kidney Disease:

Chronic kidney disease, dialysis patients, kidney failure, polycystic kidney

~ Diseases of Immunity or Autoimmune Disorders: Rheumatoid Arthritis, Inflammatory bowel disease, Ankylosing Spondylitis

~ Disorders of pituitary, adrenal & para-thyroid glands or any disorder causing growth and retardation

~ Disorders of blood or Hemolytic Disorders: Sickle Cell Disease, Thalassemia Major, Bone Marrow disorders, etc.

~ AIDS/HIV or any other sexually transmitted disease

THANK YOU

HEALTH INSURANCE

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