OPTIMA RESTORE. In-Patient Health Insurance Policy with Restore Benefit. option if Sum Insured is exhausted in the policy year.

Transcription

1 OPTIMA RESTORE In-Patient Health Insurance Policy with Restore Benefit 1 Product Advantage - First Health Insurance Product providing Restore Benefit- Automatic Reinstatement option if Sum Insured is exhausted in the policy year. - First Health Insurance Product providing Multiplier Benefit- Bonus of 50% for every claim free year accumulating upto 100% of basic sum insured. 2 1

2 USP s of Optima Restore Restore Benefit Multiplier Benefit Pre-& Post Hospitalisation Limit- 60/180 Days High Sum Insured Options 3 Why Optima Restore Scores better? Family A purchases Optima Restore Family Floater Product 3 Lacs Sum Insured Family B purchases Traditional Health Family Floater Product 3 Lacs Sum Insured 1-Jan- Family A purchased Optima Restore Product with 3 Lacs SI 1-Jan- Family B purchased Traditional Health Product with 3 Lacs SI 5-June- Husband underwent Angioplasty Claim Paid- 3Lacs 5-June- Husband underwent Angioplasty Claim Paid- 3Lacs 5-June- Optima Restore Benefit triggered. SI reinstated for another 3 Lacs 5-June- Sum Insured exhausted. No further claims to be paid 5-July- Wife suffered an accident. Claim Paid-3 Lacs 5-July- Wife suffered an accident No Claim Paid 4 2

3 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, CB reduced by 50% of basic Sum Insured at the time of renewal. 5 Sum Insured Options 15 Lacs 10 Lacs 5 Lacs 3 Lacs 6 3

4 Who can be insured Self, Spouse, Dependent Children and Dependent Parents Maximum 6 members can be insured under one Individual and Family floater plan Maximum 2 adults can be insured in one family floater plan Entry Age Cover Ceasing Age Minimum There is no maximum cover ceasing age in this policy Policy Period - 1 yr or 2 yr (s) Maximum Self 18 years 65 years Adult Dependent 18 years 65 years Child Dependent 5 years (can be covered from 91st day onwards if both parents are covered under this policy) 21 years 7 Types of Plans 8 4

5 How to insure your-self / Family Individual Health Insurance :purchased on an individual basis. Name Relationship D. O. B Sum Insured Mr. Raghav Sharma Self Lac Mrs. Aruna Sharma Spouse Lac Seher Sharma Son Lac Meher Sharma Daughter Lac Family Floater Health Insurance: one single policy takes care of the hospitalization expenses of your entire family under one Sum Insured. Name Relationship D. O. B Sum Insured Mr. Raghav Sharma Self Mrs. Aruna Sharma Spouse Seher Sharma Son Meher Sharma Daughter Lac 9 Benefits Overview The Policy pays for the benefits mentioned below: In-patient Treatment Pre-Hospitalisation Post-Hospitalisation Day care Procedures Organ Donor Emergency Ambulance Domiciliary Treatment Restore Benefit 10 5

6 In-patient Treatment The Medical Expenses for: Room rent, boarding expenses, Nursing, Intensive care unit, Medical Practitioner(s), Anaesthesia, blood, oxygen, operation theatre charges, surgical appliances, Medicines, drugs and consumables, Diagnostic procedures, The Cost of prosthetic and other devices or equipment if implanted internally during a Surgical Procedure. 11 Pre-Hospitalisation The Medical Expenses incurred in the 60 days immediately before the Insured Person was Hospitalised, provided that: i) Such Medical Expenses were in fact incurred for the same condition for which the Insured Person s subsequent Hospitalisation was required, and ii) We have accepted an in-patient Hospitalisation claim under Benefit 1a) In-patient treatment. Post-Hospitalisation The Medical Expenses incurred in the 180 days immediately after the Insured Person was discharged post Hospitalisation provided that: i) Such costs are incurred in respect of the same condition for which the Insured Person s earlier Hospitalisation was required, and ii) We have accepted an in-patient Hospitalisation claim under Benefit 1a) In-patient treatment. 12 6

7 Day care Procedures The Medical Expenses for 140 listed day care procedure mentioned in the list of Day Care Procedures (Refer Annexure 1) where the procedure or surgery is taken by the Insured Person as an in-patient for less than 24 hours in a Hospital or standalone day care centre but not the out-patient department of a Hospital or standalone day care centre. Examples of Day Care Procedures: Cataract Chemosurgery to the skin Operations on the tonsils and adenoids Surgical treatment of fistulas Hemorrhoids Lithotripsy Coronary angiography Haemodialysis Radiotherapy for Cancer Cancer Chemotherapy etc. 13 Organ Donor The Medical Expenses for an organ donor s treatment for the harvesting of the organ donated, provided that: i) The organ donor is any person whose organ has been made available in accordance and compliance with The Transplantation of Human Organs Act, 1994 (amended) and ii)the organ donated is for the use of the Insured Person, and iii)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 iv)we have accepted an in-patient Hospitalisation claim under Benefit 1a) In-patient treatment. 14 7

8 Emergency Ambulance Expenses incurred on an ambulance offered by a healthcare or ambulance service provider used to transfer the Insured Person to the nearest Hospital with adequate Emergency facilities for the provision of health services following an Emergency, provided that: i) Our maximum liability shall be restricted upto Rs 2,000 per hospitalisation, and ii) We have accepted an in-patient Hospitalisation claim under Benefit 1a) In-patient treatment. iii)coverage includes the cost of the transportation of the Insured Person from a Hospital to the nearest Hospital provided such medical services cannot satisfactorily be provided at a Hospital where the Insured Person is situated and transportation has been prescribed by a Medical Practitioner and is medically necessary. Emergency or Emergency Care means management for a severe illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a Medical Practitioner to prevent death or serious long term impairment of the Insured Person's health. 15 Domiciliary Treatment The Medical Expenses incurred by an Insured Person for medical treatment taken at his home which would otherwise have required Hospitalisation, provided that: i) On the advice of the attending Medical Practitioner, the Insured Person could not be transferred to a Hospital or a Hospital bed was unavailable, ii) The condition continues for at least 3 days, and iii)we will not make any payment for Post-Hospitalisation expenses but We will pay Pre-hospitalisation expenses upto 60 days in accordance with pre-hospitalisation benefit, and iv)no payment will be made if the condition for which the Insured Person requires medical treatment is: Asthma, Bronchitis, Tonsillitis and Upper Respiratory Tract infection including Laryngitis and Pharyngitis, Cough and Cold, Influenza, Arthritis, Gout and Rheumatism, Chronic Nephritis and Nephritic Syndrome, Diarrhoea and all type of Dysenteries including Gastroenteritis, Diabetes Mellitus and Insipidus, Epilepsy, Hypertension, Psychiatric or Psychosomatic Disorders of all kinds, Pyrexia of unknown Origin. 16 8

9 Restore Benefit Restoration of Sum Insured by automatically re-instating the basic sum insured, if the basic sum insured and multiplier benefit has been exhausted during the policy year. Basic sum insured will be re-instated only once in a policy year. Restore Sum Insured can be used for only future claims made by the Insured Person and not against any claim for an illness/disease (including its complications) for which a claim has been paid in the current policy year. If the restore sum insured is not utilized in a policy year, it will not be carried forward to any subsequent policy year. 17 Free Look Cancellation Free Look period of 15 days is offered from the date of receipt of the Policy document to review the terms and conditions of this Policy. Refund of premium after adjusting amount spent on any medical check-up, stamp duty charges and proportionate risk premium.. Free look cancellation is allowed only if no claim has been made under the Policy. Free look provision is not applicable and available at the time of renewal of the Policy 18 9

10 Portability If proposed insured is insured continuously and without interruption under any other Indian insurer s individual health insurance policy for the reimbursement of medical costs for in-patient treatment in a Hospital and proposed insured want to shift to Us on renewal, Optima Restore Policy make due allowances for: 30 days waiting periods 2 years waiting period for specific illness and treatments Waiting period for coverage of Pre-Existing Conditions. If the proposed insured transfers from any other insurer and increases the Sum Insured, then the portability benefits will be offered only in respect to the previous Sum Insured only. 19 Key Definitions Pre-existing Condition means any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms, and/or were diagnosed, and/or received medical advice/treatment, within 36 months prior to the commencement of his first being covered under an Optima Restore policy issued by us

11 Premium Payment Optima Restore provides an option to buy a plan for 2 years with a discount of 7.5% applied on the combined premiums of the 1st & 2nd year. 21 Section 80 D As per Section 80D An assessee is entitled to a deduction of Rs. 15,000 in respect of medical premia paid on the health of himself, his spouse and children. If any of them is a senior citizen, then he shall be entitled to a maximum deduction of Rs. 20,000/- as a whole. In addition thereto, if he pays insurance premia on the health of his parents, whether dependant or not, he will be entitled to additional deduction of Rs. 15,000/- (senior citizen - Rs. 20,000/-) 22 11

12 Key Exclusions Any treatment within first 30 days of cover except any accidental injury. 2 years waiting period for specific diseases. Pre-existing Conditions will not be covered until 36 months of continuous coverage have elapsed, since inception of the first Optima Restore Policy with Us. War or any act of war, nuclear weapons/materials, chemical and biological weapons, radiation of any kind. Insured Person committing or attempting to commit a breach of law with criminal intent, or intentional self injury or attempted suicide while sane or insane. Insured Person s participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing. Abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as intoxicating drugs and alcohol. Treatment of Obesity and any weight control program. Psychiatric, mental disorders; congenital internal or external diseases, stem cell implantation or surgery; sleep-apnoea. Conditions related to or arising out of HIV/AIDS. Pregnancy, miscarriage (except as a result of an Accident or Illness), maternity or birth (including caesarean section) except in the case of ectopic pregnancy. Dental treatment and surgery of any kind, unless requiring Hospitalisation. Plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment. Any non allopathic treatment. This is only a summary of the exclusions, for the complete list of exclusions please refer policy wording. 23 PPC Grid Age Group/Basic Sum 300,000; 500,000 1,000,000; 1,500,000 Insured (Rs.) 91 Days 17 Years Nil Cat Years Nil Cat Years Cat - 13 Cat Years Cat - 15 Cat Years Cat - 16 Cat - 16 Category Tests Category Tests Cat 11 ME, RUA Cat - 14 ME, RUA, FBS, CBC, Lipid Profile, PSA(Males), TMT, USG Abd (Males & Females), HbA1c, X-Ray Chest, LFT, RFT, HBsAg Cat - 12 Cat - 13 ME, RUA, FBS, CBC, Sr Creat, Lipid Profile, PSA(Males), TMT, SGOT, USG Abd(females), HbA1c, X-Ray Chest, SGPT, GGT, HBsAg ME, RUA, FBS, CBC, Sr Creat, Lipid Profile, TMT, SGOT, USG Abd (Males & Females), HbA1c, SGPT, GGT Cat - 15 Cat - 16 ME, RUA, FBS, CBC, Lipid Profile, PSA(Males), TMT, USG Abd (Males & Females), HbA1c, LFT, RFT ME, RUA, FBS, CBC, Lipid Profile, PSA(Males), TMT, USG Abd (Males & Females), HbA1c, X-Ray Chest, LFT, RFT, HBsAg, PAP smear 24 12

13 Product Advantage ME = Medical Examination Report; RUA = Routine Urine Examination; CBC = Complete Blood Count; FBS = Fasting Blood Sugar; Lipids = Lipid Profile; Sr Creatinine = Serum Creatinine; PSA = Prostate Specific antigen; TMT = Treadmill Test; USG = Ultrasonogram; SGOT Serum Glutamic Oxaloacetic Transaminase; HbA1c Glycoslated Hb; SGPT = Serum Glutamic Pyruvic Transaminase; GGT = Gamma-Glutamyl Transpeptidase; X-Ray Chest; LFT = Liver Function Test; RFT = Renal Function Test; HBsAg = Hepatitis B Surface Antigen; PAP smear. We will reimburse 50% of the expenses incurred per Insured Person on the acceptance of the proposal. The medical reports are valid for a period of 90 days from the date of Pre-Policy Checkup. 25 WHY APOLLO? Automatic Re-instatment of Amount equal to Sum Assured option if Sum Assured is Exhausted in policy year No Claim Bonus every year 50% upto 100% of Sum Asured No Capping / Sub Limit on Room Rent / ICU No Loading on Claim / Renewal No Co-payment Health Line Toll Free No. for day to day problems * * * * * 5 Stars rating for Services & Claim Settlement. If Apollo No.then what else? Pl go through the policy features before taking Mediclaim 26 13