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Health Insurance

OVERVIEW

Health Insurance is one of the most important insurance cover any financial planning can offer to an individual. Without proper health insurance, an illness or accident can wipe out your financial savings and put you and your family in debt for years. Health insurance is a type of insurance that pays for hospitalisation expenses in exchange for regular payment of premiums. You can purchase the insurance directly from the insurance company, through an agent or through an independent broker.

Even organisations provide group medical cover to their employees and their families under employer – employee group insurance.

Exclusions – medical situations which are not covered

  • Any diagnosis of diseases / undergoing of surgery / occurrence of event, whose signs or symptoms first occur within 30 days of policy start date.
  • Expenses attributable to self-inflicted injury (resulting from suicide, attempted suicide)
  • Expenses arising out of or attributable to alcohol or drug use/misuse/abuse
  • Medical expenses incurred for treatment of AIDS
  • Treatment arising from or traceable to pregnancy and childbirth, miscarriage, abortion and its consequences Congenital disease
  • Tests and treatment relating to infertility and in vitro fertilization.
  • War, riot, strike, nuclear weapons induced hospitalization

OVERVIEW

Individual Health Insurance Plan offers coverage to an individual against several listed illnesses. It also offers benefits like cashless hospitalization and various add-ons. The sum assured is determined by the health status and age of the insured.

Coverage

  • The policy covers hospitalization expense of an Individual
  • Individual will have access to cashless facility at the various listed hospitals across India and abroad.
  • Pre and post hospitalization expenses covers relevant medical expenses incurred 60 days prior to and 90 days after hospitalization.
  • Policy covers emergency ambulance charges to an average limit of Rs 1000
  • More than 100 daycare procedures are averagely covered by insurance companies, subject to terms and conditions.

Benefits

  • 10% cumulative bonus benefit for each claim free year, maximum up to 50%. cumulative bonus would be passed if continuously renewed with the insurance company.
  • No medical tests upto atleast 45 years, subject to clean proposal form.
  • 100% cost of pre-policy check-up would be refunded if the proposal is accepted and policy is issued.
  • Free Health check-up at insurance company designated diagnostic centres, at the end of 4 continuous claim-free years.
  • Income tax benefit on the premium paid as per Section 80D of the Income Tax Act.

Exclusions

  • Claim for any medical expense incurred for treatment of any illness during the 1st 30 days of policy period from the start date shall not be admissible, except those medical expense incurred as a result of an injury.
  • Pre- Existing diseases claims will not be admissible for any medical expenses incurred as hospitalisation expense for diagnosis and treatment unless 48 months of continuous coverage has elapsed since the inception of the first policy.
  • A person having a health insurance policy of a particular company can switch to another company after a predefined time gap.
  • Treatment arising from or traceable to any fertility, infertility, sub fertility or assisted conception procedure or sterilization birth control procedure not covered.
  • Any pre-existing ailment/injury not covered upto 24 continuous months from the date of policy issuance

Eligibility Criteria

This insurance is available to the person age of 18-65 years.

FAMILY FLOATER HEALTH INSURANCE

Family Floater Health Insurance plan is an umbrella insurance cover for an individuals' family.
It is the best health Insurance Plan when the question is about your family. Usually, family floater health plans offer coverage for listed illnesses to individual, spouse and kids. However, there are some insurance companies that offer these health plans to cover and individual’s siblings, parents and in-laws as well.
Family Floater plan ensures you are able to provide a single health cover for your family, including the covered parents, dependents, siblings and children.
The overall cover limit can be utilised by any of the covered member of the family , thus reducing the cost burden for the individual policy holder.

Coverage

  • All medical expenses incurred during hospitalisation are covered. These are usually the reasonable charges you incur on the advice of a Doctor, as an in-patient in a Hospital for accommodation; Boarding Expenses, organ donor expense, second opinion.
  • Pre and post hospitalization expenses cover relevant medical expenses incurred 60 days prior to and 90 days after hospitalization.
  • Covers ambulance charges in an emergency subject to a limit of Rs 1000
  • Free Medical Check-up at regular intervals provided the policy continues with the same health company.

Benefits

  • Cumulative bonus benefit for each claim free year, maximum up to a certain percentage. Cumulative bonus would be passed only when the policy is renewed with the same company.
  • No medical tests up to at least 45 years, subject to clean proposal form.
  • 100% cost of pre-policy check-up would be refunded if the proposal is accepted and policy is issued.
  • Income tax benefit on the premium paid as per Section 80D of the Income Tax Act.
  • More than 100 Day Care Procedures covered under the policy.

Exclusions

  • Any pre-existing ailment/injury not covered till upto 24 continuous months from the date of policy issuance.
  • Any diseases contracted during first 30 days of the policy start date except those arising out of accidents Any outpatient department (OPD) Treatment
  • Expenses attributable to self-inflicted injury (resulting from suicide, attempted suicide)
  • Expenses arising out of or attributable to alcohol or drug use/misuse/abuse
  • Cost of spectacles/contact lenses, dental treatment expenses that do not require hospitalisation
  • Medical expenses incurred for treatment of AIDS

Eligibility Criteria

Entry age for proposer/ spouse is 18 years to 65 years; with lifetime renewing option. Children aged 3 months to 25 years can be covered under this policy.

CRITICAL ILLNESS INSURANCE

Critical Illness plans cover serious illnesses and health conditions that might have a debilitating effect on an individual’s lifestyle and requires a considerable amount of money towards treatment. Such health condition may also lead to loss of income due to inability to work.

Coverage

Critical Illness plans cover the following diseases

  • Heart attack
  • Multiple Sclerosis
  • Stroke
  • Cancer
  • Major Organ Transplantation
  • Kidney Failure
  • Coronary Artery Bypass Surgery

Benefits

  • Include cost of care and recuperation aid
  • Free health checkups
  • No medical checkup up to 45 years of age
  • Lifetime renewal
  • 24x7 claim assistance and easy claim settlement process
  • Tax benefits under section 80 D

Exclusions

  • Critical illnesses diagnosed within first 90 days from the inception of policy
  • Death within 30 days of diagnosis of critical illness or surgery
  • Illness due to smoking, tobacco, alcohol or drug intake
  • Illness occurring due to internal or external congenital disorder
  • Any dental care or cosmetic surgery

SENIOR CITIZEN HEALTH INSURANCE

A sudden medical emergency can result in a financial crisis. To avoid this, it is prudent to take a comprehensive senior citizen Mediclaim insurance policy. Senior Citizen health insurance plan is a necessity especially for the people at retirement age.
According to the new guidelines by IRDA, every health insurance provider has to offer coverage to individuals,' up to the age of 65 years. These new guidelines will not only help individuals get coverage at later stages of their life, but will also allow them to shift their health policy to other insurers, in case they are not satisfied with their current health insurance provider. There is no dearth of insurance providers for senior citizens. However, the challenge is to choose the right one.

Coverage

  • Pre existing diseases covered after 12 months of continuous coverage.
  • Amount paid by any mode other than by cash for this insurance is eligible for relief under Section 80D of the Income Tax Act.
  • A free look period of 15 days from the date of receipt of the policy

Benefits

  • Hospitalization Coverage- These expenses include room rent, nursing and boarding charges, Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialist Fees, Cost of Medicines and Drugs - up to the limits specified in the policy.
  • Ambulance charges for emergency transportation to hospital as per specified limits.
  • Expenses on Medical Consultations as an Out Patient in a Network Hospital up to the limits specified in the policy.
  • Specific day-care procedures covered.
  • Sub-limits of coverage applicable for specified illness.

Exclusions

  • All pre-existing conditions covered after a waiting period of 1 year.
  • Any disease contracted during the first 30 days of commencement of policy.
  • Certain diseases such as hernia, piles, cataract, benign prostatic hypertrophy, hysterectomy shall be covered after a waiting period of 1 year.
  • Non-allopathic medicine.
  • All expenses arising from AIDS and related disorders.
  • Cosmetic, aesthetic or related treatment.
  • Use of Intoxicating drugs and alcohol.
  • Joint replacement surgery (other than due to accidents) will have a waiting period of four years.
  • Treatment of any mental illness or psychiatric illness.

Eligibility Criteria

Any person between 60 and 75 years of age at the time of entry can take this insurance policy.

GROUP MEDICLAIM

The Group Mediclaim Policy covers all regular employees of the company and their dependents under the scheme. There is reimbursement of expenses in the event of hospitalization due to any disease / injury.

Coverage

  • The employee and their family members are covered. Family means Employee, Employee’s parents, spouse and children only. Brothers and sisters are not covered under this scheme.
  • In case of any Additions / Deletions in the Nomination list provided by the Employee, employee has to furnish fresh form indicating the changes (eg marriage / child born)
  • On providing the nomination forms, employees are provided with the ID Cards and list of network hospitals for each of the family member. The ID cards provide details of the member, the service provider , the validity of the cover along with contact details of the TPA.

Benefits

  • Mediclaim coverage up to the age of 80 years.
  • Pre-existing diseases covered under policy
  • Maternity coverage from the inception of the policy without waiting period.
  • Mediclaim on floater basis. Under this floater scheme the sum insured for the individual family members will be added and the total insured amount will be treated as sum assured for family members.
  • Lower premium costs
  • Cashless Claims across Network Hospitals

Exclusions

  • All expenses arising from AIDS and related diseases.
  • Cosmetic, aesthetic or related treatment.
  • Claims arising due to use of alcohol and/or intoxicating /psychotropic drugs whether prescribed or not.
  • War, invasion, acts of foreign enemies, hostilities (whether war be declared or not) civil war etc.
  • Intentional self injury.
  • Any claim directly or indirectly caused by or contributed to by nuclear weapons and materials.
  • The treatment of obesity (including morbid obesity) and other weight control programs, services and supplies.
  • Congenital external illness/disease/defect.

Eligibility Criteria

Corporate/ Small and Medium Enterprises – for employees and their families Anyone from age five to 80 years can be covered

CASHLESS SERVICES

Cashless Health Insurance indicates a health treatment without the requirement to make upfront payment, as when you get hospitalized with a network hospital, you do not have to settle the bill with the hospital. The Insurance Company represented by the TPA, co-ordinates with the hospital and settles the bill.

  • The covered person under a Health Insurance Policy is issued a Health TPA ID card. If the health insurance cover is issued through the employer, you may not be issued a physical ID card but may have a E-card. This card will facilitate you to avail CASHLESS facility at the Networked Hospitals.
  • Cashless hospitalization can be availed only at the insurers/ TPAs network hospitals. The essence of cashless hospitalization is that the insured individual need not make an upfront payment to the hospital at the time of admission.
  • Cashless is only a facility extended by the Third Party Administrators to the Insured persons through their Network of Hospitals who have agreed to certain terms and conditions.
  • Cashless cannot be claimed as a matter of right and denial of a pre-authorization request is in no way to be construed as denial of treatment or denial of coverage or denial of your right to prefer reimbursement claim.
  • You can also go ahead with the treatment, settle the hospital bills and submit the claim for a possible reimbursement.

THIRD PARTY ADMINISTRATORS (TPAs)

These are Third party administrators which manage the logistics of the customer interaction with the hospital and insurance company. They ensure that the clients are able to get due health care at the tie up hospitals under the cashless scheme. Also, in case the customer goes for reimbursement of expenses, it’s the TPA that manage the operational part of the same. Though the agreement is between customer and the insurance company.

TPA

These are Third party administrators which manage the logistics of the customer interaction with the hospital and insurance company. They ensure that the clients are able to get due health care at the tie up hospitals under the cashless scheme.
Also, in case the customer goes for reimbursement of expenses, it’s the TPA that manage the operational part of the same. Though the agreement is between customer and the insurance company.

TPA Services

TPA Services provides benefits to the insured by quick cashless hospitalization and faster reimbursed mediclaim settlement. Hence we are utterly concerned about our clients to provide all comforts in health care services. These companies also provide value add services like customized, high-quality health benefits administration programs and related outsourcing services to Insurance companies.

TPA Role

The role of a TPA is to coordinate with hospitals with respect to treatment and also pass the bills on behalf of the insurance companies. The actual payment is made by the insurance company. As far as the legal contract is concerned, it is between the insurance company and the person insured. The individual insured will get an ID card issued by the TPA. This ID Card is useful and needed at the time of hospitalization.

We work with major insurance companies