Let s Uncomplicate Diabetes. Get covered for type 1 & 2 diabetes from day 1 and uncomplicate your life with the Energy plan.

Transcription

1 Let s Uncomplicate Diabetes Get covered for type 1 & 2 diabetes from day 1 and uncomplicate your life with the Energy plan.

2 FAQ s 1. What is the target market? This a specialized product targeted towards individuals suffering from Diabetes Type 1, Diabetes mellitus Type 2, pre-diabetes (IFG, IGT) and/ or hypertension. 2. Can Energy Plan be offered to people leading a Standard life? No, it can only be offered to persons diagnosed with Type 1 diabetes, Type 2 diabetes, IFG/ IGT and/or hypertension. 3. Why only diabetic/ hypertensive people are covered under this product? Energy, as a product, is built around wellness program as its core, which aims to inspire the diabetic/hypertensive to lead an active lifestyle through efficient diet management and exercise plan. Hence, it is natural to provide this plan to these people who need it the most. This kind of a plan is not required for people leading a normal life. Regular & cheaper alternatives (without wellness management programmed) would be sufficient to cater the health insurance requirements. 4. Would the insured be eligible for Portability norms under the product? Yes, this product is eligible for portability. Portability would be limited to the extent of previous sum insured + CB (if any) and waiting periods (2 years and PED) would be reduced based on number of continuous years of previous insurance. 5. What are the Sum insured options available? The SI option offered is 2, 3, 5, 10, 15, 20, 25 & 50 lacs on individual sum insured basis. 6. What is the minimum and maximum entry age? Minimum entry age 18 years and maximum entry age 65 years. 7. Why has this product been categorized as a health management program? The product has lifestyle management as its core where we would monitor the health of the individual over the period of insurance through wellness tests, inspire the insured to lead an active lifestyle by providing diet and exercise plans through health coach. We also calculate wellness score based on the evaluation through wellness tests and award renewal discounts and incentives up to a max of 25% each. This would motivate the insured to maintain good health and there by earn returns. 2

3 8. Are there any waiting periods in the product? The following are the waiting periods applicable on the product 2 years waiting period for specified illnesses 2 years waiting period on PEDs Please note that there is no waiting period of 30 days applicable, further the PED waiting period does not apply to complications associated with diabetes and hypertension. 9. Do the insured have to undergo pre-policy check? Yes. All proposals would be subject to a Pre- policy Check. PPC would be done on a cashless basis. Age\SI Rs. 200,000; 300,000; 500,000, 10,00,000, 15,00,000, 20,00,000, 25,00,000 & 50,00, Years >45 Years Medical examination report, HbA1c, Urine micro albumin, Total Cholesterol, Total Protein, SGOT, Serum Creatinine, Tread Mill Test Medical examination report, Tread mill test or ECG with 2D ECHO, Lipids, Serum Creatinine, Liver function test, Ultrasonogram Abd, HbA1C, Urine micro albumin ME = Medical Examination (Report), FBS = Fasting Blood Sugar, Lipids = Lipid Profile, Sr Creatinine = Serum Creatinine, PSA = Prostate Specific antigen, RUA = Routine Urine Examination, TMT = Treadmill Test, USG = Ultrasonogram, SGOT Serum Glutamic Oxaloacetic Transaminase, HbA1c Glycoslated Hb, Total Proteins = Serum total protein, Microalbuminurea = Urine Albumin 10. Does product offer any choice of plan options? Product offers 4 plan options: Gold without Co-pay Gold with 20% Co-pay Silver without Co-pay Silver with 20% Co-pay 11. What are the differences between Gold and Silver Plans? Variants/ Parameters Wellness Test Gold Insured can undergo wellness tests at our empanelled diagnostic centers on a cashless basis. Or Insured s choice of DC which is approved by Us on reimbursement basis. Silver Insured s choice of DC which is approved by Us. Reimbursement Test reports In case the Insured undergoes tests at Insured s choice of DC which is approved by Us, we would reimburse up to Rs. 2000/- on submission of bills. If tests are undergone at Network DC, DC would share test reports with AMHI If tests are undergone at Insured s choice of DC, it is Insured s responsibility to send report in prescribed time to AMHI. Insured will have to bear the cost of wellness tests. Insured s responsibility to send report in prescribed time to AMHI 3

4 12. Who is a Health Coach and how would they assist the insured? Health coach is a dedicated support person who would help an insured member: To Keep a track on the health status In creating diet and fitness plans By reminding the scheduled wellness test requirements To understand the working of the wellness portal and health management plan By providing general advice on health and wellness By updating the insured s health pal on the progress made by the insured. Health coaches are clinical nutritionist and para medics, and would be backed by qualified doctors. 13. Who is the health Pal? Health Pal can be any relative or friend chosen by the insured, who will be updated with the progress in the health of the insured. 14. How often will the Health Pal be contacted by the health coach with health updates and follow ups? Health Pal will be contacted 6 times during the policy year On policy inception, post welcome call to the Insured Month 3 Month 6 Month 9 Month 10 Month Can the insured or Health Pal call the Health Coach directly? If yes, what are the contact details? Yes, you or health pal can reach health coach on toll free no: Would the insured be required to go through IVR or the call would directly land at the Health Coach s desk? Also, please clarify how will we ensure that an insured mapped to a particular Health Coach will be able to access the same Coach upon subsequent calling for continuity & personal connect? Yes, you would be required to go through an IVR (Option 4). Call can be responded by any of the available health coaches. To provide reference to previous communication each health coach on completion of a call would save notes for future reference. This enables continuity & personal connect. 17. How will health coach identify the insured when an inbound call is made? For inbound calls insured would be required to provide your user ID to access past call or activity history. 18. If doctor advises for any additional test or repeat of Wellness Test 2, will the cost of the test(s) be borne by AMHI? AMHI will not bear cost of any additional tests which may be prescribed by the doctor. 19. What is the process for getting approval of the non-network DC to get my wellness tests conducted? In case of Gold plan if insureds choose to use DC other than our empanelled network, our wellness team will inform you of the diagnostic center options available to undergo wellness test. Insured would have to pay at the center, send reports to prescribed ID or postal address & retain bills for subsequent reimbursement. 4

5 20. What are the advantages of Gold Plan with wellness test taken at network DC s? Insured can undergo medical tests at network DC s on cashless basis. Personalized assistance to set up wellness test at our quality network DC. Reminders so that you do not miss your wellness test The test reports will be automatically sent to AMHI and get updated on the wellness portal without the insured having to physically dispatch reports. Insured need not go through the process of reimbursement Large network for added location convenience 21. Where do the insured send reports in case he/she visits a non-network but approved center? To avail wellness discount and incentive the wellness test reports can be sent in either in hard or soft format. Sending reports by would be beneficial as you would not incur any courier cost and also it is a faster and secure mode. Hard copy Wellness Team Apollo Munich Health Insurance Co. Ltd., 2nd & 3rd Floor, ilabs Centre, Plot No , Udyog Vihar, Phase-III, Gurgaon , Haryana. Soft copy wellness@apollomunichinsurance.com 22. What are the test which would be conducted under Wellness 1 & 2? There will be two wellness tests conducted at specific intervals of policy period in which different health parameters will be evaluated. These will be monitored & one can track the same through their personalized login on wellness portal. Period Wellness Test 1 Wellness Test 2 Diagnostic Tests HbA1c, Blood pressure Monitoring, BMI HbA1c, FBS, Total Cholesterol, Creatinine, High-density lipoprotein (HDL), Lowdensity lipoprotein (LDL), Triglycerides (TG), Total Protein, Serum Albumin, Gammaglutamyltransferase (GGT), serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), Billirubin, Total Cholesterol : HDL Cholesterol, ECG, Blood pressure Monitoring, BMI, Doctor Consultation 23. How will wellness portal help the insured in the disease management? Wellness portal will help in- Maintaining appointments/ set alerts Store health reports Track health performance & check risk modulation Provides access to Health coach for any health related queries View your reward points after Wellness Tests and renewal incentive earned at the end of the year 24. Is there any prescribed format/mer form that will be used essentially by the consulting doctor in Wellness test- 2? If yes, how does this prescribed format/mer form reaches the approved non-network DC? Yes, there is a prescribed format and the same would be sent via by health coach while approving a DC for wellness test. 5

6 25. Will all approved non-network DCs have doctors for consultation in wellness test 2? In case, if doctor not available in the approved non-network DC, can an insured take the doctor s consultation at any un-approved center/clinic/ hospital and what is the process for the same? Approved DC would have doctor available for consultation and consultation at any un-approved center/clinic/ hospital will not be approved. 26. Please share some examples of Claims which are caused by Diabetes and Hypertension that would be payable under Energy Plan from Day 1 of the policy. Heart attack resulting in CABG Kidney Failure requiring dialysis 27. Please explain that as to what extent the PPC will help in identifying all complications of Diabetes and Hypertension? Diabetes affect most of our vital organs which support life and well being, clinical tests prescribed under PPC and medical examination report would help in collecting information on current status of these vital organs like Heart, circulatory system, Kidney, Liver, eyes etc. 28. What are the examples related to Other Health Expenses as paid under Wellness Incentive? These typically would be health related expenses which are not covered under health insurance like expenses incurred on purchase of health food items ( diabetic food, protein shakes) etc. 29. In Gold plan, person goes for wellness test 1 in network DC on cashless basis. Now, for wellness test 2 he goes to a non-network DC and pays Rs What would be the limit of reimbursement in this case? In case of wellness test undertaken at non network DC s, we would reimburse actual expenses or maximum of Rs.2000/- in total. This would apply incase insured person undergoes either or both wellness tests at non network Dc s. 30. On what basis is the wellness score assigned? Wellness score is computed utilizing the health parameters measured in the wellness tests. The scores are assigned on various parameters as per below given table Wellness Rater Examination Type Reading Score HbA1c (%) Blood Pressure Wellness Test 1 Upto Systolic Diastolic Systolic Diastolic <120 < >139 >= Wellness Test 1 Taken Yes 1 6

7 HbA1c (%) Blood Pressure Body Mass Index (BMI) Total Cholesterol : HDL Cholesterol Ratio Wellness Test 2 Upto Systolic Diastolic Systolic Diastolic <120 < >139 >= Upto to Wellness Test 2 Taken Yes 1 Both tests taken Yes 1 Diabetologist Consultation Yes On what basis do the insured get a discount? Based on cumulative wellness score, discount will be applicable as per grid below Wellness score Discount on renewal premium % % % % Less than 8 No discount Product also provides equivalent amount of re-imbursement for expenses incurred on health Example- Consultation charges Medicines and drugs Diagnostic expenses Dental expenses Other miscellaneous Medical Expenses 32. If due to diabetes, the person requires undergoing transplantation of Pancreas; will the claim be payable under inpatient benefit and the corresponding organ harvesting expenses of the donor under Organ Donor benefit? Our product do not cover expenses related to transplantation of pancreas, (please refer to general exclusions Section 2.C.xii.w of the policy wordings), as the transplanted pancreas become non functional after certain duration and this line of treatment is expensive and relatively new in India. 7

8 33. Will Health coach have access to all reports on IHP, including those uploaded by the insured (other than PPC, Wellness test 1 and wellness test 2)? While filling up of Health Risk Assessment (HRA) on IHP, an option is provided to insured, only on affirmation health coach would be able to access other reports uploaded by insured. PPC, Wellness tests reports would be viewed by the health coach. 34. As per the scoring rater in IHP, we consider only four tests i.e. HbA1c, BMI, BP and Total Cholesterol for calculating renewal discounts. Please confirm whether Health Coach will track and discuss with the insured about other tests also like SGOT, SGPT, GGT and creatinine, serum albumin and bilirubin. If yes, please share the format or process for monitoring the same? Yes, tests like SGOT, SGPT, GGT and Creatinine, serum albumin and Billirubin would be monitored by health coach and would be discussed during review calls. 35. Please explain medical conditions pertaining to un-controlled diabetes and un-controlled hypertension. Cases for above mentioned scenarios can be accepted, decision would be based on PPC & declarations made on PF. 36. Will we issue policy for hypoglycemia under type 2 diabetes? Can be considered based on PPC results & underwriting. 37. What is the exact time frame (beginning & ending) for completing Wellness test 1 and 2? Activity Policy Inception Date Wellness Test 1 Scheduling Call by Health Coach Wellness test 1 Must be completed and report submitted Wellness Test 2 Scheduling Call by Health Coach Wellness test 2 Must be completed and report submitted Wellness discount generated Risk End Date Timelines Inception 3 Month 5th Month 8th Month 9th Month 10th Month Policy End Date 38. For a insured who is not computer literate and thus cannot use IHP, is there any other way that he can get his health information like health graph s, wellness scores/incentives, reminders, additional discount, etc.? Under current plan all communication related to wellness plans would be available on IHP or would be sent by Can grandson propose his grandparents under Energy plan? Yes 40. Customer undergoes some tests and later applies for Energy, will we consider him to go for just the balance tests? Yes, we would consider the reports if tests done are within 90days days of submission of proposal. Proposer would be required to undergo the balance tests at our network DC. 8

9 41. What is the TAT for settlement of Wellness test 1 & 2 expenses to the insured in case of approved DC in Gold Variant? 21 working Days from receiving of data from the insured member 42. If an insured gets admitted in hospital for Dengue within 15 days of the policy issuance, is the claim payable? Yes 43. Please share the specific reason why do we ask for income details in case proposer is other than insured.? Annual income of the proposer is requested to ascertain financial capability to continue paying premiums and to check sum insured requested commensurate with annual income. 44. In case insured undergoes wellness test 1 or 2 post the time frame, will we still consider those tests for health rewards? Insured would not be eligible for health rewards if wellness tests are not completed in prescribed time. 45. Within how many days post issuance of the policy insured will receive the user ID and password for IHP? Is it through only or SMS as well? On issuance of policy insured person s personal account would be created in IHP. Login ID and a default password would be sent via & mobile phone no (as mentioned on the PF). This information would be shared within 10 days of policy issuance. 46. Can an insured buy multiple policies of 10 Lac each in Energy plan? If yes please clarify, how will we apply wellness discount on multiple policies? No. 47. What if the insured is not able to take either or both wellness tests? You would be informed well in advance and reminded of approaching wellness test through a call and via s. If you choose not to undergo wellness test or miss your scheduled wellness test in the defined timelines you would not be eligible for wellness points for missed wellness test, but your coverage would go on uninterrupted. 48. Do the insured get any reimbursement in case he/she chooses not to undergo wellness tests? We would not reimburse wellness test cost if you miss or choose not to undergo wellness tests. 49. Would the insured be eligible for the discount even if a claim has been made during the policy period? The wellness discount is not based on claims status, in case you have undergone wellness test during the policy period you would be eligible for wellness discount based on your wellness score. 50. How will the insured get to know the date of wellness tests and the score earned through these tests? We will keep a track & will contact you at an appropriate time. You would be able to track your health status and score on your personalized health portal. 51. Can the insured claim renewal incentive any time or is there a validity time frame for the same? You can claim renewal incentive only within the same renewal year. It will not be carried forward if not claimed. 52. What is the maximum storage capacity available for storing the data with respect to PPC reports, Wellness reports, Personal health reports etc. in the Integrated Health Portal? In case more space is required, is there any provision to upgrade the capacity? You can store data up to 1 GB and there is no provision to upgrade the capacity. 9

10 53. Please explain the wellness tests covered in the Policy? Test Description of Test What does it monitor HbA1c Blood Pressure BMI FBS Total cholesterol Creatinine High density lipoprotein (HDL) Low density lipoprotein (LDL) HbA1c (glycated or glycosylated haemoglobin) is a lab test that shows the average level of blood sugar (glucose) over the previous 3 months. Blood pressure measures the force applied to the walls of the arteries as the heart pumps blood through the body. Under normal situations it should be systolic/ dystolic - 120/80 Body mass index (BMI) is an indirect measure of body fat based on height and weight. Fasting blood sugar (FBS) measures blood glucose after you have not eaten for at least 8 hours. Fasting increases plasma glucose levels in the body which get balanced through insulin secreted in the body. A total cholesterol test measures all the cholesterol in your blood Creatinine test measures the level of creatinine in your blood. HDL test is to measure HDL level In blood. HDL helps remove fat from the body by binding with it & carrying it back to the liver for disposal. LDL test is to measure LDL level in blood. LDL carries mostly fat and only a small amount of protein from the liver to other parts of the body. It is used to estimate average blood glucose level. It also shows how well is diabetes controlled in the last 2 to 3 months. It monitors high blood pressure which increases the risk of heart failure, heart attack, stroke, and kidney failure. A high BMI predicts the development of several diseases, including diabetes. Diabetes is a serious condition, as it can lead to complications such as kidney failure and heart disease It measures plasma glucose level & is often the first test done to check for prediabetes and diabetes. This test is often done to determine your risk for coronary artery disease which further leads to heart disease. The test is done to see how well your kidneys work. Creatinine is removed from the body entirely by the kidneys. If kidney function is abnormal, creatinine levels will increase in the blood. A high level of HDL cholesterol may lowers chances of developing heart disease or stroke. A high level of LDL may increases chances of developing a heart disease. 10

11 Triglycerides (TG) Total protein Serum Albumin Gammaglutamyltransferase (GGT) Serum Glutamic Oxalocetic Transaminase (SGOT) Serum Glutamic Pyruvic Transaminase (SGPT) Bilirubin Triglyceride tests are blood tests that measure the total amount of fatty substances (triglycerides) in the blood. Total protein test is done to measure total protein in the blood A serum albumin test measures the amount of albumin protein in the the blood. Gamma-glutamyl transpeptidase (GGT) is a test to measure the amount of the enzyme GGT (produced in liver) in the blood. This test is done to estimate amt of this enzyme in blood. This is an enzyme that helps liver build and break down proteins. In case of damage, they get released in blood. This test is done to estimate amt of this enzyme in blood. This is an enzyme that is present in liver cells. In case of damage, they get released in blood. A bilirubin test measures the amount of bilirubin in a blood sample. It is produced when the liver breaks down old red blood cells. It monitors fat (lipid) in the blood that in higher level leads to heart diseases. Total protein show how well the liver is making proteins that body needs to fight infections and perform other functions. This test help in detecting liver disease or kidney disease, or if the body is not absorbing enough protein. This test is used to detect diseases of the liver or bile ducts High level of enzyme in blood indicate liver damage. High level of enzyme in blood indicate liver damage. It determine whether there s a blockage in liver s bile ducts or if detect increased destruction of red blood cells. 54. If an insured is given an option to get covered by us with loading and chooses not to accept it, then we refund the amount. Subsequently, he decides to accept our decision and wants to take the policy. Will a fresh PPC be conducted by us in such a case? A fresh PPC will be conducted if the PPC report is of older than 90 days. 55. What is the TAT for uploading the reports of Wellness Test into IHP? 3 working days from the day AMHI receives the reports. 56. If SI is enhanced then on which premium amount will the wellness discount be applicable the earlier premium or the enhanced premium? In case of SI enhancement the wellness discount would be applied on the premium of enhanced SI. 57. Can an insured nominate his Agent to be the Health Pal? The health pal nomination is completely up to the insured. But it would be beneficial to the insured if any family member is chosen as health pal. 11

12 58. Will the DC check the sender of the SMS at the time of Test? Can the SMS be forwarded to a different mobile number and still be acceptable to the DC for conducting the tests? Yes 59. How will the insured be communicated about the wellness discount and incentive earned? The information of the wellness discount will be provided on the renewal letter, IHP portal and will also be communicated by the health coach in the final call for the year. 60. A customer wants to port his policy with basic Sum Insured of Rs. 2 lacs and Cumulative bonus of Rs. 1 lac in his previous policy. Now, He applies for Rs. 3 lac Sum Insured in Energy plan. On what Sum Insured, waiver of waiting period will be applicable? While proposing the proposer can request to add the accrued cumulative bonus of 1 lac along with the SI of 2 lac. On porting to Energy plan wavier of waiting period would be granted for 3 lac (SI 2 lac + 1 lac). 61. If AMHI has rejected a claim for non disclosure of diabetes under Easy Health or Optima Restore plan, can this insured migrate his policy into Energy? Will this insured get waiver of waiting periods? Any non disclosure will have an appropriate action applied on current policy. A decision may also be taken to cancel the policy ab initio. Hence, we cannot provide a standard answer to this case and each policy will be dealt individually. 62. Will there be scenarios in Energy wherein the proposal will be deferred on the basis of medical underwriting? What would be the deferment period? Please explain with examples? The cases can be deferred but the period would entirely depend on the underwriting and may differ from case to case. 63. Can an insured undergo wellness test 2 in 6th month of the policy or before the schedule if he is travelling abroad or for any other reason in the 8th to 10th month of the policy? The tests will require to be undergone as per scheduled dates only. Exceptions will only be entertained with deviation approval. energy@apollomunichinsurance.com SMS energy to Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2 nd & 3 rd Floor, ilabs Centre, Plot No , Udyog Vihar, Phase III, Gurgaon , Haryana Corp. Off. 1 st Floor, SCF-19, Sector-14, Gurgaon , Haryana Reg. Off. Apollo Hospitals Complex, /82/J III/DH/900 Jubilee Hills, Hyderabad, Telangana , India. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding a sale IRDAI Registration Number CIN: U66030TG2006PLC UIN: APOHLIPI8126V031718