Health Insurance – Handbook

Index

 Health Insurance Terminologies

 HDFC Ergo – Optima Restore

 Religare- Care

 Max Bupa- Health Companion

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 Health Insurance Terminologies
The term ‘Health Insurance’ relates to a type of insurance that essentially covers your
medical expenses. A health insurance policy like other policies is a contract between an
insurer and an individual / group in which the insurer agrees to provide specified health
insurance cover at a particular “premium” subject to terms and conditions specified in
the policy.

• What a Health Insurance policy would normally cover

A Health Insurance Policy would normally cover expenses reasonably and necessarily
incurred under the following heads in respect of each insured person subject to overall
ceiling of sum insured (for all claims during one policy period).
a) Room, Boarding expenses
b) Nursing expenses
c) Fees of surgeon, anesthetist, physician, consultants, specialists
d) Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines,
drugs, diagnostic materials, X- ray, Dialysis, chemotherapy, Radio therapy, cost of pace
maker, Artificial limbs, cost or organs and similar expenses.

• What is Inpatient Treatment

The treatment provided to the insured upon admission to a hospital for more than 24 hours
on the written advice of a medical practitioner.

It may include room charges, nursing expenses, ICU charges, surgeon’s fee, doctor’s fee,
medicines, operation theater charges, diagnostics etc.

• What are pre & post hospitalization expenses

Pre – Hospitalization: Medical Expenses incurred prior to hospitalization to understand the
patient’s health condition before hospitalization. It may include cost of Diagnostic, Dr.
consultation and Medicine.

Post – Hospitalization: Medical expenses incurred after hospitalization on the written advice
of the treating doctor. It may include cost of medicines, doctor consultation, diagnostic test
etc.

• What is out patient benefit

Out-patient benefit means wherein hospitalization is not required. It includes coverage for
expenses like:

 Visit to a general Practitioner/specialist consultant for diagnosis/treatment

 Medicines from Pharmacy on written advice of medicine practitioner

 Investigation and Diagnostic charges towards diagnostic tests

 Routine physical & prevention examinations

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• What is Day care treatment
The treatment provided to the insured upon admission to a hospital for less than 24hours
due to advancement of technology is called Day Care treatment. For Eg:

 Cataract
 Stone removal surgery
 Chemotherapy
 Radiotherapy
 Dialysis

• What is Domiciliary treatment

The medical expenses incurred by an insured person for medical treatment taken at home,
which otherwise would have required hospitalization

 Could not be transferred to a hospital

 Hospital bed was unavailable
 Recommended by MBBS Dr.
 The condition continues for at least 72 hours

• What is Organ donor benefit

The medical expenses for an organ donor’s treatment for the harvesting of the organ
donated, provided that:

 The organ donor is nay person whose organ has been made available in accordance
and compliance with “the transplantation of Human organs act, 1994”
 We will not pay the donor’s pre and post – medical expenses or any other medical
treatment for the donor consequent on the harvesting, and
 We .have accepted an In- patient hospitalization claim under benefit In-patient
treatment

• What are Sub-limits

The capping on the amount payable for the particular benefit is called Sub Limit. The capping
is usually a percentage of sum insured or an absolute amount.

Sub-limit on room rent / ICU charges

This is defined either as

 % of SI per day; or [E.g. 1% of SI per day]

 Flat amount per day; or [ Rs. 2000 per day]
 As a combination of (i) and (ii) with upper cap. [1% of SI per day, subject to Rs. 3000
per day]

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• What is co-payment
A Pre-defined percentage of the total claim amount as per the policy contract, that is borne
by the insured /policyholder is called Co-Payment.

For Eg – 20% co-pay after completing the age of 60 years.

Mr. Kapoor, a 63 year old businessman opts for 5 Lac SI in January 2012. In July 2012, he is
hospitalized.
Total Bill = Rs. 4 Lac
In this case, Mr. Kapoor needs to pay Rs.80k (20% of 4 Lac) from his own pocket as co-
payment feature in the policy.

• What is deductible
Deductible is the amount paid by the insured/policyholder before an insurer will pay any
expenses. Deductible can be:

 Per Claim Basis

 Insured/Policyholder will pay deductible amount from his own pocket in each claim
before insurer begins to cover any treatment

 Per Policy Basis

 Insured/Policyholder will pay amount from his pocket each year before insurer
begins to cover any medical costs

• What are waiting periods

 Initial Waiting Period – 30 days
Applicable to treatment of any critical illness or unexpected seasonal illness during the
first 30 days from the date of purchase.

Critical Illness: Cancer, Heart-attack, kidney failure, Major Organ Transplant, Stroke ,
Paralysis, etc.

Seasonal Illness: Dengue, Malaria, Jaundice, Typhoid, Swine-flu, etc.

Medical expenses incurred due to an accident will be covered from the first day itself.

 Specific Waiting Period – 2 years

For slow growing illnesses - Named surgeries/ procedures are not covered in the policy
during the first 2 policy years.

Sample procedures: Cataract, Hernia, Piles, Joint knee replacement, Kidney Stones, etc.

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  Pre Existing Disease Waiting Period – 4 years
Any pre-existing ailment/injury/condition within 48 months prior to issuance of the first
policy will not be covered for the first 4 continuous policy years.

 Permanent Exclusions are never covered

Drink & Drive, Suicidal Attempts, Cosmetic Surgery, Congenital Disease, HIV Aids, etc.

• Claim Process:

Claim Process

Non Network
In Network Hospital
Hospital

Cashless Claims Reimbursement

Reimbursement Process: In this process customer

Cashless card required: Payment will have to bear the medical expenses and later on
directly done by the Insurance after complete submission of the documents
company insurance company with transfer the money to the
customer’s bank account.

Details: Customer Name, Age, Documents Required: Claim form, KYC,

Policy number, Policy Validity Cancelled cheque, Original Bills and prescriptions

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• Types of plans:

 Individual Plan
In a single individual policy a maximum of 6 insured members can be covered. No more
than 4 adults. (Including the proposed insured) or 4 children can be insured under one
policy. The 4 adults can be a combination of Self, Spouse, or set of parents.

Every individual will have their separate SI

Policy number would be same however; premium is calculated as per the individual’s
age.

 Family Floater Plan

In a family floater a maximum of 6 insured members can be covered. No more than 2
adults. (Including the proposed insured) or 4 children can be insured under one policy.
The 2 adults can be a combination of Self, Spouse or set of parents.

Combined SI for all the insured members.

In a family floater the age of the eldest member will be considered while computing
premium for the family.

• Free look Period:

 The 15 days free look period shall be applicable at the time of purchasing the policy of
the Policy and is not applicable and available at the time of Renewal of the Policy or in
cases of Portability.
 If the customer have any objections to any of the terms and conditions, they may cancel
the Policy stating the reasons for cancellation and provided that no claims have been
made under the Policy
 We will refund the premium paid by the customers after deducting the amounts spent
on pre-insurance medical check-up (if any), stamp duty charges and proportionate risk
premium for the period of cover.

• Tax Benefit: Section 80D

Maximum Tax benefit for Health From FY 2019
insurance premium paid Your family
means Self, Spouse & dependent children Your Family Parents Total

No one in the family is above 60 years of

25000 25000 50000
age

You, spouse and children are less than 60

years. Either parent (mother or father) is 25000 50000 75000
a senior citizen

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• Booking Process:

Online
Booking
Process

Underwriting Underwriting
not required required

Instant
Accept Loading Changes Reject
Issuance

Customer
Refund
Policy Issued Consent
Initiated
required

Policy Issued

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8
Notes

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Notes

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 HDFC ERGO Health Insurance

 Plan Name - Optima Restore

• Product USPs:
 Multiplier Benefit
 Restore Benefit
 No Capping
 No Co-payment

• Multiplier Benefit:
 Available for every claim free year
 Sum Insured increased by 50% accumulated maximum up to 100% of SI
 In the event of Claim, Multiplier Benefit is reduced by 50% of basic Sum Insured at the
time of renewal.

Year 1 Year 2 Year 3 Year 4 Year 5

Base Sum Insured 500,000 500,000 500,000 500,000 500,000

Multiplier Benefit NA 250,000 500,000 250,000 500,000

Total Amount (At 500,000 750,000 10,00,000 750,000 10,00,000

beginning of the
year)

Example: If Insured Person opts for Optima Restore Policy with 5 Lacs Sum Insured &
claimed in 3rd year. Multiplier Benefit will be functional as follows-:

• Restore Benefit:

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 Company restores entire sum insured if exhausted fully or partially in between the policy
year.

 Restore is done once in a year.

 Same person can utilize restore amount for the same or different illness.
 Remaining amount cannot be carried forward to the subsequent year.

Scenario Claim

(Family consisting of Insured A & Insured B) SI=5 lac, Multiplier Payable

Benefit 2.5 lac

Insured A undergoes angioplasty Restore Sum Insured is

activated after claim payment
Claims: 2 lac Claim paid: 2 lac

After 2 months ( in the same policy year) Insured Claim is now payable for similar
illness or condition for same
(A ) again undergoes CABG procedure Claims: 1.5lac insured member
Claim paid: 1.5 lac

Insured B ( in the same policy year) undergoes Claim also payable for other
insured member for similar
angioplasty procedure illness/condition
Claims 1 lac Claims paid: 1lac

Insured A ( in the same policy year) hospitalized due to injuries Single claim size cannot exceed
sustained in an accident Claims=8lac sum of base SI and Multiplier
benefit(if any) In this case
Claim paid=7.5lac 5+2.5=7.5 lac

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 • Who can be insured
Minimum Maximum

Self 18 years 65 years

Adult Dependent 18 years 65 years

Child Dependent 91 days 25 years

• Benefits Overview:

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• Health Advisory Benefit:
 Lump sum benefit of Rs. 5000 if the insured takes treatment in a network hospital
recommended by HDFC ERGO.

 Amount would be credited to customer`s account only after the cashless has been
approved

• Waiting periods

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  Initial Waiting Period – 30 days
Applicable to treatment of any critical illness or unexpected seasonal illness during the
first 30 days from the date of purchase.
 Specific Waiting Period – 2 years
For slow growing illnesses - Named surgeries/ procedures are not covered in the policy
during the first 2 policy years.
 Pre Existing Disease Waiting Period – 3 years
Any pre-existing ailment/injury/condition within 3 years prior to issuance of the first
policy will not be covered.
 Permanent Exclusions are never covered
Drink & Drive, Suicidal Attempts, Cosmetic Surgery, Congenital Disease, HIV Aids, etc.

• Discount
 7.5% discount in case the Insured Person is paying 2 years premium in advance as single
premium.

• Decline Conditions
 Members with any of the following conditions/ ailments or history of the same, may be
rejected subject to underwriting:
 Diabetes type 1 or 2
 Pregnant female life from the second trimester up to 1 month of child birth.
 Person suffering from any critical illness
 Persons suffering from multiple diseases.
 Etc.

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Notes

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Notes

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 Religare Health Insurance
 Plan Name - Care
• Product USPs:
 Annual Health Checkup
 Automatic Recharge
 Super No Claim Bonus
 Ayush Benefit

• Benefits Overview:

Sum Insured
Benefits 3, 4 lakhs 5, 7, 10 lakhs 15, 20, 25, 30, 40 50, 60,75 lakhs
lakhs
Hospitalization Covered Covered Covered Covered
Room rent/ 1% of sum Single Private Single Private Single Private
specification insured per day Room Room upgraded Room upgraded
to next level to next level
Pre 30 days 30 days 30 days 30 days
Hospitalization
Post 60 days 60 days 60 days 60 days
Hospitalization
Domiciliary Covered up to Covered up to Covered up to Covered up to
10% of Sum 10% of Sum 10% of Sum 10% of Sum
insured insured insured insured
Day Care 541 541 541 541
treatment
Auto restoration Automatic Automatic Automatic Automatic
(Condition, recharge of sum recharge of sum recharge of sum recharge of sum
Premium, Limit) insured at no insured at no insured at no insured at no
extra costs extra costs extra costs extra costs
Organ Donor Covered up to Covered up to Covered up to Covered up to
Rs.50,000 Rs.1,00,000 Rs.2,00,000 Rs.3,00,000
Critical Illness Covered up to Covered up to Covered up to Covered up to
Cover sum insured sum insured sum insured sum insured
Maternity Not covered Not covered Not covered Upto Rs 1 Lakh
Alternative Upto Rs 15000/- Upto Rs 20000/- Upto Rs 30000/- Upto 40000/-
Treatment
Ambulance Upto Rs 1500/- Upto Rs 2000/- Upto Rs 2500/- Upto Rs 3000/-
Second Opinion Covered Covered Covered Covered
Care Anywhere Not Covered Not Covered Not Covered Covered
NCB 10%-50% 10%-50% 10%-50% 10%-50%

• Who can be insured

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 Minimum Maximum

Self 18 years Lifelong

Adult Dependent 18 years Lifelong

Child Dependent 91 days 25 years

• Recharge Benefit:
Company restores entire sum insured if exhausted fully or partially in between the policy
year.

 Restore is done once in a year.

 Same person cannot utilize recharge amount for the same illness.
 Remaining amount cannot be carried forward to the subsequent year.

Scenario Claim

(Family consisting of Insured A & Insured B) SI=5 lac Payable

Insured A undergoes angioplasty Restore Sum Insured is

activated after claim payment
Claims: 2 lac Claim paid: 2 lac

After 2 months ( in the same policy year) Insured Claim is now payable for
different illness or condition for
(A ) undergoes Dengue treatment Claims: 1.5lac same insured member
Claim paid: 1.5 lac

Insured B ( in the same policy year) undergoes Claim also payable for other
insured member for similar
angioplasty procedure illness/condition
Claims 1 lac Claims paid: 1lac

Insured A ( in the same policy year) hospitalized due to injuries Single claim size cannot exceed
sustained in an accident Claims=8lac sum of base SI and NCB
benefit(if any) In this case 5 lac
Claim paid=5lac is payable

• No Claim Bonus:
 Available for every claim free year

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  Sum Insured increased by 10% accumulated maximum up to 50% of SI
 In the event of Claim, NCB is reduced by 10% of basic Sum Insured at the time of
renewal.

Year 1 Year 2 Year 3 Year 4 Year 5

Base Sum Insured 500,000 500,000 500,000 500,000 500,000

NCB NA 50,000 1,00,000 50,000 1,00,000

Total Amount (At 500,000 550,000 600,000 550,000 6,00,000

beginning of the
year)

Example: If Insured Person opts for Optima Restore Policy with 5 Lacs Sum Insured &
claimed in 3rd year. NCB will be functional as follows-:

• Waiting periods
 Initial Waiting Period – 30 days
Applicable to treatment of any critical illness or unexpected seasonal illness during the
first 30 days from the date of purchase.
 Specific Waiting Period – 2 years
For slow growing illnesses - Named surgeries/ procedures are not covered in the policy
during the first 2 policy years.
 Pre Existing Disease Waiting Period – 4 years
Any pre-existing ailment/injury/condition within 4 years prior to issuance of the first
policy will not be covered.
 Permanent Exclusions are never covered
Drink & Drive, Suicidal Attempts, Cosmetic Surgery, Congenital Disease, HIV Aids, etc.

• Discount
 7.5% discount in case the Insured Person is paying 2 years premium in advance as single
premium.
 10% discount in case the Insured Person is paying 3 years premium in advance as single
premium.

• Optional Covers

 Unlimited Automatic Recharge Benefit

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  Recharge of SI unlimited times
 Recharge amount can be used for future unrelated claims
 Any unutilized amount will not be carried forward to subsequent policy year

 No Claim Bonus Super (Super NCB)

 Base policy is increased by 60% for the first 2 years and 10% for the next 3 years.
 Bonus cannot exceed 150% of Base SI
 In case of a claim in any policy year, bonus will decrease in the same order.
(FIFO)

 Smart Select
 If this optional cover is opted, policy holder is entitled to get 15% discount
 However, if customer is admitted in a non-smart select hospital for treatment,
then 20% co-pay would be applicable

• Pre-policy check-up
 Customer has to undergo medical test, if age is >60 years.
 Or, Sum Insured is > 40 lacs

Cost: It is borne by insurance company if policy is accepted however; if policy is

rejected then medical cost is deducted from premium.

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Notes

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 Notes

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 Max Bupa Health Insurance

 Plan Name – Health Companion

• Product USPs:
 Refill Benefit
 Guaranteed No Claim Bonus
 Free Health Check-up
 Ayush Benefit

• Benefits Overview:

Overall Sum VARIENT 1 VARIENT2 VARIENT3

Insured (SI) 2 3 4 5 7.5 10 12.5 15 20 30 50 100
Rupees LAC LAC LAC LAC LAC LAC LAC LAC LAC LAC LAC LAC

IPD
COVERED UPTO COVERED UPTO BASE COVERED UPTO BASE SUM
BASE SUM SUM INSURED INSURED
INSURED
Pre & Post 60 & 90 days 60 & 90 days 60 & 90 days
Day Care All Covered All Covered All Covered
Procedures
OTHER BENEFITS
Emergency UPTO RS.3000 UPTO RS.3000 UPTO RS.3000
Ambulance
No claim bonus 20 % of basic sum 20 % of basic sum 20 % of basic sum insured upto
insured upto max insured upto max 100% max 100%
100%
Refill benefit Upto base SI Upto base SI Upto base SI
Vaccination in Upto Rs. 2500 Upto Rs. 5000 Upto Rs. 7500
case of animal
bite
Ayush Treatment Upto Base SI Upto Base SI Upto Base SI
Health checkup Once in a 2 years Annually Annually
Domiciliary COVERED UPTO COVERED UPTO BASE COVERED UPTO BASE SUM
Hospitalization BASE SUM SUM INSURED INSURED
INSURED
Hospital Cash Rs.1000/day Rs.2000/day Rs.4000/day

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 • Who can be insured
Minimum Maximum

Self 18 years Lifelong

Adult Dependent 18 years Lifelong

Child Dependent 91 days 21 years

• Refill Benefit:
Company restores entire sum insured if exhausted fully or partially in between the policy
year.

 Restore is done once in a year.

 Same person cannot utilize recharge amount for the same illness.
 Refill amount and remaining SI can be clubbed and used for different illness.
 Remaining amount cannot be carried forward to the subsequent year.

Scenario Claim

(Family consisting of Insured A & Insured B) SI=5 lac Payable

Insured A undergoes angioplasty Restore Sum Insured is

activated after claim payment
Claims: 2 lac Claim paid: 2 lac

After 2 months ( in the same policy year) Insured Claim is now payable for
different illness or condition for
(A ) undergoes Dengue treatment Claims: 50K same insured member
Claim paid: 50 K

Insured B ( in the same policy year) undergoes Claim also payable for other
insured member for similar
Accident treatment illness/condition
Claims 50K Claims paid: 50K

Insured A ( in the same policy year) hospitalized due to injuries Clubbing allowed, In this case 5
sustained in an accident Claims=8lac lac is payable from refill and 2
lac from remaining SI
Claim paid=7lac

• No Claim Bonus:

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  Available every year, irrespective of claim.
 Sum Insured increased by 20% accumulated maximum up to 100% of SI
 In the event of Claim, NCB is not reduced.

Year 1 Year 2 Year 3 Year 4 Year 5

Base Sum Insured 500,000 500,000 500,000 500,000 500,000

NCB NA 1,00,000 2,00,000 3,00,000 4,00,000

Total Amount (At 500,000 600,000 700,000 800,000 9,00,000

beginning of the
year)

Example: If Insured Person opts for Health Companion Policy with 5 Lac Sum Insured &
claimed in 3rd year. NCB will be functional as follows-:

• Waiting periods
 Initial Waiting Period – 30 days
Applicable to treatment of any critical illness or unexpected seasonal illness during the
first 30 days from the date of purchase.
 Specific Waiting Period – 2 years
For slow growing illnesses - Named surgeries/ procedures are not covered in the policy
during the first 2 policy years.
 Pre Existing Disease Waiting Period – 4 & 3 years
Any pre-existing ailment/injury/condition will be covered after 4 years in Variant1 and
after 3 years in Variant 2&3.
 Permanent Exclusions are never covered
Drink & Drive, Suicidal Attempts, Cosmetic Surgery, Congenital Disease, HIV Aids, etc.

• Discount
 12.5% discount on 2nd year premium, in case the Insured Person is paying 2 years
premium in advance as single premium.

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Notes

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Notes

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