Easy Health Ready-Reckoner

Transcription

1 Easy Health Ready-Reckoner

2 Index Index 2 1 Sum Insured & Variants 4 2 Insurability Insurable persons Entry Age Floater policies Individual policies Critical Illness Checklist for Proposal Form Basic checks Proposal form Checklist for Additional Documents Age Proof Address Proof Proposer not getting covered himself or covering self alone Financial Underwriting: Special Cases 10 6 Declined Conditions List 10 7 Premium payment Cheque Dishonour Pre Policy Check Up 12 9 Risk Start Date Logic 16

3 10 Portability Renewals Endorsements Glossary Claim Procedure USP s of Easy Health Considerations for choosing right Sum Insured 24

4 1 Sum Insured & Variants Easy Health is available as individual and floater policy in three variations with variable benefits and sum insured levels: Possible Sum Insured (SI in Lakh) - Individual Possible Sum Insured (SI in Lakh) - Family Floater Standard Exclusive Premium Standard - Floater Exclusive - Floater Premium Floater The policy will be issued for a period 1/2 year. The Sum Insured of the dependent insured members should be equal to or less than the Sum Insured of the Policy Holder. In case where two or more children are covered the Sum Insured for all the children must be same. Parents sum insured should be equal to of higher than those on CDs. If proposer is requesting for cover on his/her parents or parent in law, same Sum Insured must be opted for both Parents or parent in law (Father and Mother). 2 Insurability 2.1 Insurable persons

5 2.2 Entry Age Policy Holder: Minimum 18 years and Maximum 65 years Adult Dependent: Minimum 18 years and Maximum 65 years Child Dependent: Minimum 5 years and Maximum 25 years o Child between 91 days and 5 years can be insured if either parent is covered under Easy Health policy Cover Ceasing Age: Nil There is no cover ceasing Age for Critical Illness Rider Premium is calculated on completed years of age as on the last birthday 2.3 Floater policies The maximum permissible family size cannot exceed 4 insured s per policy. No more than 2 adults (including the proposed insured) can be insured under one family floater policy. PH (Policy holder) would either be the proposer himself if getting insured in the policy, or the oldest insured in the policy (parents, grandparents, parent in law,or spouse of the proposer). AD (Adult dependent) can be spouse, either set of parents, grantparents or parent in law of the proposer. CD (Child dependent) can be natural or adopted children or grandchildren of the proposer. 2.4 Individual policies The maximum permissible members cannot exceed 6 insured s per policy. No more than 4 adults (including the proposed insured) can be insured under one Individual policy. PH (Policy holder) would either be the proposer himself if getting insured in the policy. AD (Adult dependent) can be spouse, either set of parents r, grand partents or parent in laws of the proposer. CD (Child dependent) can be natural or adopted children or grandchildren of the proposer. 2.5 Critical Illness Critical illness Rider can be opted under the all variant. The Critical Illness % can be chosen on All or None basis at 50% or 100% of the Base Sum Insured subject to minimum of 100,000 and maximum of 10,00,000, and the % opted for all insured to be same. No critical illness to be offered to the child, without parents being covered. This rule applies to all eligible members of a family seeking insurance irrespective of number of policies. The percentage opted should be same for every member. Example: Insured Name / Age Sum Insured ( Individual) Critical Illness Rider ( 100% ) Self ( 38 ) 4 Lacs 4 Lacs 2 Lacs Spouse ( 35 ) 4 Lacs 4 Lacs 2 Lacs Son ( 9 ) 3 Lacs 3 Lacs 1.5 Lacs Daughter ( 7 ) 1Lacs 1 Lacs 1 Lacs Critical Illness Rider ( 50%) Insured Name / Age Sum Insured ( Family Floater) Critical Illness Rider ( 100% ) Self ( 38 ) 3 Lacs 1.5 Lacs 3 Lacs Spouse ( 35 ) 3 Lacs 1.5 Lacs Critical Illness Rider (50%)

6 Son ( 9 ) 3 Lacs 1.5 Lacs Daughter ( 7 ) 3 Lacs 1.5 Lacs Please Note: Critical Illness rider new addition to existing Easy health or Maxima policy at renewal, would not warrant compulsory medical examination (as currently). Prevailing PPC grid logic as per attained age and requested Sum Insured be used to trigger PPC requirement (if any). Effectively <=45 year old can add CI rider up to 5 lacs to his policy without undergoing PPC, subject to underwriting. 3 Checklist for Proposal Form 3.1 Basic checks i) All questions must be answered as per advice in the proposal form. ii) Each question in section 6A, 6B, 6C and 6E (Medical declaration) must be answered individually for all insureds. Section 6C should be replied to in all cases if any adverse medical declaration noted in section 6A/6B, else same may be replied as No or N/A, but blank response would not be acceptable. Section 6D alone is acceptable if blank. iii) Any overwriting or corrections must be counter signed by the proposer. Use of whitener is not allowed. iv) N/A to be captured only for sections where the question is not relevant to the gender (Q No 13 of Sec 6A and Q No 19 & 20 of Sec 6B). v) Each page of all of the documents submitted needs to be checked thoroughly. vi) NEFT form (which is part of proposal form ) must be mandatorily filled while submitting the proposal. 3.2 Proposal form i. Name and address: a) Name and address should be correctly filled in with 6 digit PIN code. b) Either mobile or Telephone number should be mentioned. Mobile number should contain 10 digits, and landline number should have correct STD code of the city as prefix & contain correct number of digits. Total digits in the landline number should be 11 including the STD code. (E.g. Gurgaon landline number containing 7 digits, or Metro number with 8 digits). c) E mail address should be provided (if any). d) Salutations: Age Title Gender 0 15 Master Male 16 and above Mr Male 0 12 Baby Female Miss Female 22 and above Ms Female For Married Mrs Female For Divorcee/Single Ms Female ii. Nationality: Nationality should be mentioned. If nationality mentioned is other than Indian, refer guidelines below. a) Those currently working or settled in India are eligible for the cover e.g. NRI/PIO who has returned back to India and gainfully employed, or Foreign national who has taken up Indian assignment, etc. b) Coverage may be extended to people based outside India as well, subject to prior medical underwriting approval and proposal form been signed in India by the proposer only. c) Those working in India for a continuous period of 6 months or have valid Visa for a period corresponding to requested policy period may be allowed subject to the following

7 a) Copy of all pages of passport showing Visa and recent Entry/Exit stamps from India b) Current VISA validity of at least 6 months duration iii. Marital status: If widow/divorced/separated and proposed insured is female, family details form must be submitted. iv. Income details: Annual income of the proposer needs to be mentioned at required place. v. Occupation: Profession needs to be ticked on proposal, and details should be mentioned, regarding exact occupation in case if option ticked as Others, exact nature of duties in case if option ticked as Salaried and exact line of business in case if option ticked as Self employed against each insured for accurate occupation classification. Even health insurance is not offered to occupation class IV (AC4) occupations. vi. Benefit section: Only one plan (Standard/Exclusive/Premium) to be ticked with Type (either Individual or Floater, and not both). Policy Period to be either ticked 1 Year/ 2 Year. vii. Height & weight, DOB (Date of birth), Occupation and Gender details: Height & weight, DOB, Occupation and Gender information of all insured should be mentioned clearly in the respective column. viii. Relationship: Relationship of Insured to Proposer should be mentioned in the respective column. Allowable relationships include Self, Spouse, grandchildren, either set of parents or grandparents or parents in law. The only exception to this that may be allowed is when children are proposed insureds and both the parents are no more. In such cases close relatives (Uncle / Aunty / / siblings) may be allowed to propose without any prior approval with a declaration from proposer in this regard. ix. Sum insured: For floater type applications only sum insured against Insured 1 may be mentioned, else for individual type applications respective sum insured to be mentioned for all insured individually in the sum insured column. Cases where floater option is ticked as yes and same sum insured is mentioned against each insured Ais acceptable for login, However in case if different sum insured is mentioned against each insured, same has to be rectified with a countersign from proposer. CI benefit sum insured to be mentioned against each insured individually in exact value. x. Existing insurance details & portability: Previous insurance policy No, Name of the insurer, Insurance coverage period, sum insured and claims details (if any) should be mentioned in the column provided. If previous insurance policy details are filled in, then question related to desire for continuity benefits must be answered as Yes/No. xi. Nominee details: If provided, Name, Address and Relationship of nominee with proposer needs to be mentioned in the column provided. The nominee mentioned in the proposal form must be an immediate relative of the primary proposer only (Father, Mother, Spouse, Brother, Sister, Son or Daughter). For all other proposed insured (other than the proposer) the nominee shall be the proposer him/herself. xii. Medical questionnaire: All questions against each insured to be answered individually as Yes/No (Y/N), except in case of female life question (Q No 13 of Sec 6A or Q No 19 & 20 of Sec 6B). For all answers as Yes/Y, details needs to be provided in relevant column of Sec 6C against each insured individually. Relevant documents (if any) may be attached for faster processing of cases, avoiding want of calling for additional information post underwriting. xiii. Personal habits: Tobacco, Pan masala and Alcohol consumption habits of all insured along with quantities & frequency (if replied as Yes/Y), should be mentioned individually. xiv. All declarations: All declarations must be signed by the proposer. If signed in vernacular language or thumb impression, vernacular declaration needs to be completed with witness name & signature. xv. If payor and proposer are the same, check the signatures on cheque & application form if payment mode is cheque. If not matching, please get declaration from the proposer on usage of different signatures for the insurance application and cheque, if not provided in additional information column. This declaration must carry both the signatures used. xvi. Premium payment (amount, mode and payor details): Payment details viz Instrument details, Name of the payor, Bank details, Relationship of payor with Proposer, Date and Amount to be mentioned in the column. xvii. If involve PPC or there is adverse medical declaration and there is change in age band (Premium/PPC perspective), customer should be pre-informed if requirement (PPC/Risk loading premium/consent, whichever is later) is not complied before DOB, revised premium shall be charged and/or PPC be called as per new age band.

8 xviii. In case if age band is changing so that exceeding maximum entry age criteria for the product (25 years/65 years) within 30 days and involve PPC or there is adverse medical declaration, same should not be logged in. xix. Further in case if insured s age band in changing within next 30 days so that exceeding maximum entry age criterion but doesn t require a PPC (25 years), but other members proposed have adverse medical declaration or require PPC, same should not be logged in. 4 Checklist for Additional Documents 4.1 Age Proof Age proof if submitted needs to be verified for correctness of DOB mentioned on proposal i.e. DOB mentioned on proposal and that on age proof submitted for the insured should match. When the age proof does not capture DOB and captures age only, then age should match with the completed age as per DOB mentioned in the application form. Valid/Standard age proof: i) School/College Certificate (Progress Report, Mark Sheet, Bonafied Certificate, Leaving Certificate, Transfer Certificate etc) ii) Passport iii) Municipal Birth Certificate iv) Employment Certificate showing DOB from Govt/public sector v) Domicile Certificate vi) Nursing Hospital Certificate/Discharge Card if minor is below 5 yrs vii) Baptism or Marriage Certificate (for Catholics only) viii) PAN Card ix) Driving License Non-standard age proof: Must be accompanied by Affidavit from the Customer for DOB confirmation under oath (on 100 Rs stamp paper attested by judicial magistrate only) i) Voter's I Card ii) Ration card iii) ESIS Card iv) Pension Card v) Dependent ID/Family card 4.2 Address Proof Address on proposal should match with that on the address proof submitted. List of acceptable address proof i) Address & Contact Number Proof on Company Letter Head / Employee ID cards ii) Telephone Bill, Post Paid Mobile Bill, Broadband Bill iii) Rent Agreement/ Lease Agreement/ Property Tax / Water Tax /House Tax/ Electricity bill iv) Driver s license/passport/ Gas Connection/Ration Card /Arms & ammunition License v) Bank Statement / Bank Passbook / Fixed Deposit Certificate / Credit Card Statement vi) Any Life Insurance: Premium Receipt / Welcome letter /Policy Bond etc.. vii) Last year s Health Policy document (Portability cases) viii) Any vehicle RC Copy ix) Pan Card Intimation letter / Voter Id Card/ Aadhar Card/ Income Tax Returns x) PPF /NSC /any other Investment Certificate

9 xi) Any Government issued document for Address Proof (from Gram Panchayat etc) xii) Monthly Maintains bills for Bldg Society/ Chwals/Flats/Plots xiii) Regiment Certificate for Army Personnel xiv) In absence of above an Affidavit from the Customer for Address & Telephone Number confirmation List of acceptable standard address proof is as per the circular shared by operations department. Any subsequent circular shall supersede this list. Note: i. Address proof is compulsory for Agency, Partnership, AES and Digital (offline cases) ii. Any Bill or Statement for Bank, Credit Card, Mobile, Bank Pass Book etc. That is submitted to us, should not be more than 3 months old from Bill Generation date or Bill Payment date. iii. All policies from Thane/Ulhasnagar location (up to 3 lacs sum insured) and Nashik, Ghaziabad, Faridabad, Bulandshehar, Vapi, Dhaund, Talegaon (Pune) and Jalgaon locations within city/area limits only (for all sum insureds) have standard age proof (for proposer), photo ID proof (for proposer and all insureds of age 18 and above), address proof (of proposer) and photograph (mandatory for all insureds except child dependent of age less than 5 years). Responsibility to ascertain adherence to this guidelines vest with local or branch operation person, who would identify the cases as per criteria defined and confirm to the requirements by mentioning the same on the check list. List of cities shared is not exhaustive, and shall be updated on regular basis. 4.3 Proposer not getting covered himself or covering self alone Married person proposing for self only or proposing for eligible relations excluding self, part of the family for insurance, widows, single non working females, housewives etc: 1) Married person proposing for self only without covering rest of dependent family members, may be allowed subject to i) Family members are covered under individual health insurance policy with Apollo Munich or other insurers if sum insured requested is in excess of 3 lacs (supporting documents like schedule/renewal notice must be submitted) ii) OR members are uninsurable for the product (Uninsurable health condition or over age), declaration in additional information column may suffice iii) For sum insured up to 3 lacs, same would be allowable irrespective of cover on family members iv) Else return the form to sales 2) Married person or earning children (married/single) proposing for rest of family members without covering self may be allowed subject to i) Proposer himself is covered for sum insured equal to of higher than proposed on members, under individual health insurance policy with Apollo Munich or other insurers if sum insured requested in excess of 3 lacs (supporting documents like schedule/renewal notice must be submitted) ii) OR proposer is uninsurable for the product (Uninsurable health condition or over age), declaration in additional information column may suffice iii) For sum insured up to 3 lacs, same would be allowable irrespective of cover on proposer iv) Else return the form to sales 3) Widow/divorced/separated females (Self proposed or proposed by children who are not dependent on her) may be allowed coverage subject to i) Eligible (dependent) members are getting covered in same policy (i.e. Child dependents) for equal or lesser amount of cover ii) Maximum sum insured allowable to the extent of Rs if not earning or unearned income only, as per eligibility in case if earning iii) Family details to be provided in family details form iv) Else return the form to sales 4) Housewife or married female with unearned income (Self proposed or proposed by children or spouse who are not dependent on her) may be allowed coverage subject to

10 i) If husband is not covered/uninsurable (Uninsurable health condition or over age) or covered for sum insured less than 3 lacs, maximum sum insured allowable on housewife would be to the extent of Rs ii) Sum insured allowable may extend up to the amount of coverage on husband beyond 3 lacs, if husband is covered under indemnity based individual health policy with AMHI or with other insurer (supporting documents like schedule/renewal notice must be submitted) iii) Else return the form to sales 5) Single Non-working female life coverage may be allowed subject to i) Maximum up to 3 lacs sum insured, irrespective of parents or siblings coverage ii) Maximum sum insured allowable to the extent of parents/siblings sum insured (supporting documents like schedule/renewal notice must be submitted if sum insured requested for more than 3 lacs) Equal or higher coverage on parents Equal amount of coverage on siblings OR i) members are uninsurable for the product (Uninsurable health condition or over age), declaration in additional information column may suffice ii) Else return the form to sales 6) Student life coverage may be allowed subject to i) Maximum up to 3 lacs sum insured, irrespective of parents or siblings coverage ii) Maximum sum insured allowable to the extent of parents/siblings sum insured (supporting documents like schedule/renewal notice must be submitted if sum insured requested for more than 3 lacs) Equal or higher coverage on parents Equal amount of coverage on siblings iii) OR members are uninsurable for the product (Uninsurable health condition or over age), declaration in additional information column may suffice iv) OR if education loan taken then coverage may be allowed up to 75% of the loan amount irrespective of parent s or sibling s coverage, maximum of higher of above or 5 lacs (supporting documents like loan sanction letter and disbursement advise must be submitted) v) OR if getting stipend (PhD, MBBS/MD/MS, etc) coverage may be allowed as per eligibility irrespective of parent s or sibling s coverage (Refer financial underwriting section) vi) Else return the form to sales 4.4 Financial Underwriting: i) Sum insured asked for roughly should not exceed 5 times of annual income of the proposer. ii) Premium to income ratio for all insurance policies of the person (life and health) should not exceed 20%. 5 Special Cases i) Employer employee cases: Employee would be the proposer and Employer can ONLY be the premium payor. ii) Counter offer (Risk loading) cases: a. If loading is paid in cash or any other mode except cheque/credit card, written consent is mandatory for issuance b. If loading is paid by cheque/credit card by proposer, consent is not mandatory c. If loading is paid by cheque/credit card by person other than proposer, consent is mandatory 6 Declined Conditions List Members with any of the following conditions / ailments or history of the same shall not be offered health insurance cover currently. i) Diabetes Mellitus or Impaired glucose tolerance ii) Coronary Artery Disease (Angioplasty/Coronary bypass/heart attack) iii) Congestive Heart Failure/ Conduction Abnormalities of Cardiac System/ Pace maker implantation

11 iv) Cerebrovascular Accident (Stroke) v) Malignancy or Cancer (Leukemia, Sarcoma, etc) vi) Auto Immune Diseases (Rheumatoid Arthritis, SLE, Ankylosing spondylitis etc.) vii) Renal Transplant/ Congenital disorders of Renal System viii) Cirrhosis (Alcoholic/Nonalcoholic) ix) Multiple Sclerosis x) Epilepsy xi) Mental Retardation xii) Genetic Disorders xiii) Psychiatric disorder xiv) Renal failure /Chronic renal disorder/ ESRD (End stage renal disorder) xv) Paralysis xvi) Inflammatory bowel disease (Crohn s disease and Ulcerative colitis) xvii) Pregnant female life from the second trimester up to 1 month of child birth. They may be covered in their first trimester and post-one month of delivery, with necessary documentation. Period Decision 0-3 month of pregnancy Considered 4 month of pregnancy till 1 month after delivery Declining > 1 month after delivery Considered Please note that this list is enumerative only & conditions may be added or deleted based on our experience. All such changes shall be communicated to all the concerned before implementation in future. 7 Premium payment Cheques / Demand Drafts / Cash and Credit cards are accepted Cheques are permitted from the following entities: -Self, Spouse or any of the blood relative of proposer or a business partner or employer (Employer employee case). In case of business partner, consent / declaration of other partners is not manadtory if the premium is paid from partnership firm`s bank account. Forms wherein premium is paid by third party (one who is neither proposer nor one of the insured), a third party declaration needs to be submitted. Benefits of Sec 80 D under income tax would be available for payment in any mode other than cash. This benefit shall be available to the payor of the premium only, if either proposer, one of the insured or Son/daughter/Father/Mother/Spouse of the insured. 7.1 Cheque Dishonour The cheque has to be drawn in favour of Apollo Munich Health Insurance Company Limited only. In course of a cheque dishonor, the application or policy is cancelled.there are two options for the customer The customer has to sign a declaration [(available at branches indicating his health status has not changed and he agrees to change the policy start date to new date of payment and pay again within 7 days of the cheque dishonor. (For portability cases payment against cheque dishonour has to be as per login criteria for e.g. For PPC portability case payment should be received at least 30 days prior to previous policy expiry) Customer can fill up a new proposal form and apply again if the above is not fulfilled within 7 days. It has to be demand draft /Cash/Credit card.

12 For both the above cases, payment will accepted only by demand draft / Cash / Credit Card. Cheque will not be accepted again or represented. 8 Pre Policy Check Up PPC is triggered only after the applications are logged in at the branches. Member should be educated on PPC tests that will be done. CUSTOMERS SHOULD T GO ON THEIR OWN FOR PRE-POLICY CHECK. Health India / any other TPA appointed by Apollo Munich will make an appointment with the customers over the phone. They need to carry a copy of photo ID card for the tests. Incase a customer does not turn up for the test / indicates he is not interested in tests/ not reachable, then the sales team will be informed. Agents need to check up with the customer, take the new timings and date and inform local office. HO will inform the TPA for customers preference. If the customer does not get the PPC done within 21 calendar days from the date of login of the application form the prospect will be cancelled (7 days in case of portability case) Reimbursement Incase a proposal is accepted after PPC, Apollo Munich will reimburse 50% of the expenses incurred per insured person. The medical reports are valid for a period of 90 days (Sub-standard findings in PPC)/ 180 days (Standard findings in PPC) from the date of Pre-Policy Checkup. PPC applicability should be decided based on the age and sum insured opted under the product for any member with Apollo MUNICH, as per PPC grid of the individual product only. This guideline would be followed unless there is any specific communication in this regard from medical underwriting. if the customer is not interested in undergoing PPC then the customer should give a written note for cancellation of prospect or call our toll free to request cancellation. This would help sending the refund immediately to the customer rather waiting for automated cancellation after 21 days. Any reduction in benefit amount i.e. SI reduction or deletion of CI benefit would not alter the medical requirements, once triggered. Medical requirements once triggered cannot be waived. PPC Grid with details of tests and costs is as below WITHOUT CRITICAL ILLNESS RIDER Age/ SI (Rs.) Lac Upto 2 > 2 to 5 > 5 to 10 >10 Lacs & upto 50 Lacs Nil Nil Nil ME,FBS,TMT,RUA,CBC,Li pids,sgot,serum creatinine,psa(males),u SG Abd(females),HbA1C, SGPT, GGT, HBsAg (Cat 17)

13 46-55 ME, FBS, ECG (Cat 1) ME, RUA, FBS, ECG, CBC, TC (Cat 3) ME, RUA, FBS, CBC, ECG, TC (Cat 3) ME,FBS,TMT,RUA,CBC,Li pids,rft,lft,psa(males),usg Abd(males and females),hba1c, HBsAg (Cat 19) ME,RUA,FBS,ECG (Cat 2) ME, RUA, FBS, CBC, Lipids, ECG (Cat 4) ME, RUA, FBS, CBC, Lipids, SGOT, TMT, HbA1c, Sr Creat, PSA (males), USG abd(females) (Cat 5) ME,FBS,TMT,RUA,CBC,Li pids,rft,lft,psa(males),usg Abd(males and females),hba1c, HBsAg (Cat 19) ME,FBS,RUA,CBC,Lipids,SGOT,Serum creatinine,psa(males), USG Abd(females),Total proteins, ECG, 2D ECHO (Cat 22) ME,FBS,RUA,CBC,Lipids, HbA1C,RFT,LFT,PSA(mal es),usg Abd(females),ECG, 2D ECHO (Cat 23) ME,FBS,RUA,CBC,Lipids, HbA1C,RFT,LFT,PSA(mal es),usg Abd(females),ECG, 2D ECHO (Cat 23) ME,FBS,RUA,CBC,Lipids, HbA1C,RFT,LFT,PSA(mal es),usg Abd(females),ECG, 2D ECHO (Cat 23) WITH CRITICAL ILLNESS RIDER Age/ SI(Rs in Lacs) Upto 2 > 2 to 5 > 5 to 10 >10 Lacs & upto 50 Lacs Nil Nil ME,RUA,FBS,ECG,TC, CBC (Cat 3) ME, FBS, ECG (Cat 1) ME, RUA, FBS, CBC, TMT, Lipids (Cat 6) ME, RUA, FBS, CBC, TMT, HbA1c, SGOT, Sr Creat, Lipids, PSA(males),USG Abd(females) (Cat 5) ME,FBS,TMT,RUA,CBC,Lip ids,sgot,serum reatinine, PSA(males),USG Abd (females),hba1c, SGPT, GGT, HBsAg (Cat 17) ME,FBS,TMT,RUA,CBC,Lip ids,rft,lft,psa(males), USG Abd(males and females),hba1c, HBsAg (Cat 19) ME, RUA, FBS,ECG (Cat 2) ME, RUA, FBS, CBC, Lipids, TMT, SGOT, Sr Creatinine (Cat 7) ME, RUA, FBS, CBC, Lipids, TMT, HbA1c, LFT,RFT,PSA (males), USG Abd (females) (Cat 8) ME,FBS,TMT,RUA,CBC,Lip ids,rft,lft,psa(males), USG Abd(males and females),hba1c, HBsAg (Cat 19)

14 61-65 ME,FBS,RUA,CBC,Li pids,hba1c,rft,lf T,PSA(males),USG Abd(females),ECG, 2D ECHO (Cat 23) ME,FBS,RUA,CBC,Lipids,HbA1C,RFT,LFT,PSA(m ales),usg Abd(females),ECG, 2D ECHO (Cat 23) ME,FBS,RUA,CBC,Lipids, HbA1C,RFT,LFT,PSA(mal es),usg Abd(females),ECG, 2D ECHO (Cat 23) ME,FBS,RUA,CBC,Lipids,H ba1c,rft,lft,psa(males ),USG Abd(females),ECG, 2D ECHO (Cat 23) In case of switch from existing Easy health to Optima restore, PPC applicability would be as per the grid below Sum Insured Opted at the time of Renewals - Optima Restore Existing Sum Insured Age band <= 17yrs 1 Lac, 2 Lac, 3 Lac, 4 Lac, 5 Lac, 7.5 Lac, 10 Lac 3 Lakh 5 Lakh 10 Lakh 15 Lakh Sum Insured Opted at the time of Renewals - Optima Restore Existing Sum Insured 1 Lac, 2 Lac, 3 Lac, 4 Lac, 5 Lac, 7.5 Lac, 10 Lac Existing Sum Insured Age band 18-45yrs 3 Lakh 5 Lakh 10 Lakh 15 Lakh Sum Insured Opted at the time of Renewals - Optima Restore Age band > 45yrs 3 Lakh 5 Lakh 10 Lakh 15 Lakh 1 Lac 2 Lac, 3 Lac 4 Lac, 5 Lac, 7.5 Lac 10 Lac No Medicals required will be required as per applicable grid for given age and sum insured Regarding acceptance of such cases a. In case if there is no PPC requirement or adverse medical declaration on proposal form or claim in previous policies, login would be allowed even during grace period without any deviation approval. Existing Risk Start Date (RSD) logic would be followed & needs to be communicated to the customer. b. In case if there is a PPC requirement or adverse medical declaration on proposal form or claim in previous policies, login would be allowed only up to expiry of previous policy. Existing RSD logic would be followed, no deviation in this regard will be allowed. In case of switch from existing Easy health to Optima restore, PPC applicability would be as per the grid below

15 Age <=17 Existing Sum Insured (Optima Restore) Easy Health Sum Insured opted at renewal 1 to CI CI CI CI CI CI CI CI CI CI CI CI CI CI Age Existing Sum Insured (Lac) Easy Health Sum Insured opted at renewal 1 to CI CI CI CI CI CI CI CI CI CI CI CI CI CI Age > 45 Existing Sum Insured (Optima Restore) Easy Health Sum Insured opted at renewal 1 to CI CI CI CI CI CI CI CI CI CI CI CI CI CI 3

16 Risk Start Date Logic Risk start date would be later of the Proposal sign date, Login date, Requirement completion date and previous policy expiry date (in case of portability case). Example 1) Payment made through cheque dated Requested Start date Proposal sign date Case status N PPC/N Portability Application received date at AMHI office Start date should be as application form received at AMHI is Example 2) Payment made through cheque dated Requested Start date Proposal sign date Case status N PPC/N Portability Application received date at AMHI office Start date should be as application form received at AMHI is Example 3) Payment made through cheque dated Requested Start date Proposal sign date Case status N PPC Previous Policy expires on Application received date at AMHI office Start Date should be as previous policy renewal date (requirements completed prior to previous policy expiry). Example 4) Payment made through cash dated Requested Start date Proposal sign date Case status N PPC Previous Policy expires on Application received date at AMHI office Start Date should be as previous policy renewal date (requirements completed prior to previous policy expiry). Example 5) AMHI Renewal case Payment made through cheque dated Previous policy expired Start Date should be however portability benefits will be extended in the policy as application received within 30 days from the date of expiry of the previous as per IRDA circular. Example 6) Payment made through cheque dated Requested Start date

17 Proposal sign date Case status PPC/N Portability Application received date at AMHI office PPC done Reports received at AMHI office Start Date should be the day when PPC was done (later of application received date, requirement complete date) Example 7) Payment made through cheque dated Requested Start date Proposal sign date Case status PPC/Portability Case Previous Policy expires on Application received date at AMHI office PPC done PPC reports received Requirement raised Requirement fulfilled and received at AMHI office Start Date should be as previous policy renewal date (requirements completed prior to previous policy expiry). Example 8) Payment made through cheque dated Proposal sign date Case status N PPC Application received date at AMHI office as is holiday Start Date should be as application received date is Example 9) Payment made through cheque dated Proposal sign date Case status N PPC Application received date at AMHI office Start Date should be as application form signed date and proposal received date is Portability Most health insurance plans offered by general or health insurers in India have waiting periods, exclusions which reduce based on the number of years of continuous cover. Portability will ensure that these accrued benefits are transferred at par to the new insurer at the time of porting and consumers do not lose on these benefits while switching insurers. The credit gained will be applicable to: i) General waiting period ii) Waiting periods for coverage pre-existing conditions iii) Any time bound exclusions (for example 2 year waiting periods for listed conditions in Easy Health) Application timelines i) In case of adversity in proposal form / claim declaration/ppc as per medical grid - 21 days before renewal date ii) In case of no adversity in proposal form, no claim declaration and no PPC as per medical grid 2 working days before renewal date iii) In case of medicals to be conducted or additional information required, customer must complete the same or provide requisite documents within 7 days of intimation from the company. Documentation For availing portability benefits following documents are to be submitted in addition to duly filled portability form-: i) Copy of the previous years Policy Schedule issued by the previous Insurer OR Renewal Notice ( We would provide portability benefits to the extent of documentary proofs provided /made available, in case we do not receive information from your existing insurer.)

18 ii) Self-declaration by customer regarding no claims made iii) Questions regarding previous and existing health insurance details in the Proposal Forms should be mandatorily filled. iv) If there is a claim in existing policy, then discharge summary, investigation and follow up report copies v) If there is a past medical history, then consultation papers, prescription, investigation, treatment and report copies. Incase of higher cumulative bonus polices, the bonus amount transferred shall be the lower of the accumulated sum insured under previous plan or upto 50% of the SI under Easy Health (as the maximum cumulative bonus available under Easy Health is restricted to 50%of SI). Case of NCB/NCD in the existing product ( to be ported to AMHI) a. If incoming product is a CB (Cumulative bonus) product then existing guidelines of CB calculation and matching would prevail. b. If NCD product, in that case i. Customer declaration of claim for all previous policy years on proposal form (Q No 5) be mandatory. ii. Policy documents for latest 3 or 4 years (as per ported product s PED e.g. Easy health 3 years) only need to be submitted if 1. NCD reflected in submitted documents as more than Zero (if same should be more than Zero as per incoming product guidelines). 2. NCD reflected in first policy (no previous policy no or reference is given) as Zero, but in rest following years as more than Zero (if same should be more than Zero as per incoming product guidelines). iii. In case of claim as declared on proposal form or NCD is Zero (if same should be more than Zero as per incoming product guidelines), medical documents related to claim and all year s policy documents would be mandatory. If No CB/NCD product (i.e. No CB AND No NCD) in that case I. Customer declaration of claim for all previous policy years on proposal form (Q No 5) be mandatory. II. Policy documents for latest 3 or 4 years (as per ported product s PED e.g. Easy health 3 years) only need to be submitted. III. In case if customer opts for lesser year of portability as per submitted documents, then declaration in same regard needs to be in place on proposal form and we shall process for portability benefit as per given documents. IV. In case of claim as declared on proposal form, medical documents related to claim would be mandatory. 11 Renewals i. Apollo Munich policy s renewal request can be accepted maximum up to 60 days prior to policy expiry date ii. iii. In case of any requirement raised for renewal (Member addition, SI enhancement, CI addition, etc) e.g. PPC, Add info, Risk loading or exclusion, etc, same needs to be complied to within 7 days. Grace Period allowed -30 days post expiry of policy iv. Sum Insured Enhancement Sum Insured can be enhanced only at the time of renewal subject to no claim have been lodged/ paid under the policy. If the insured increases the sum insured one grid up, no fresh medicals shall be required. In cases where the sum insured increase is more than one grid up, the case may be subject to medicals (refer guidelines below). In case of increase in the Sum Insured waiting period will apply afresh in relation to the amount by which the Sum Insured has been enhanced. However the quantum of increase and pre-policy check up requirements shall be at the discretion of the company. a) No PPC be called for cases in renewal, where there is No SI enhancement, member addition or CI rider addition requested

19 b) SI enhancement or CI rider addition is allowed only in case if no claim in the policy. However request may be logged in and final decision on acceptability would be taken after complete underwriting only. c) PPC is mandatory for all CI rider addition cases, irrespective of the age (Category would be confirmed post underwriting) d) In case if SI enhancement requested of 1 band only, No PPC be required unless called by medical underwriter based on underwriting guidelines e) In case if SI enhancement requested for more than 1 band If revised policy benefits (SI) falls under non-medical limits of PPC grid as per attained age band, No PPC would be required unless called by medical underwriter based on underwriting guidelines. If revised policy benefits (SI) falls under medical limits of PPC grid as per attained age band, PPC would be mandatory. f) In case if CI rider is requested at the time of renewal, then Medical Tests may be called for on a case to case basis as per the Underwriting decision. 12 Endorsements Endorsements Type Policy Cancellation Change of Plan Change in Sum Insured Pre- Inception Documents Required Post-Inception/ Renewal - - Letter from the Client Premium payment. Letter from the Client Premium payment. only at Renewal only at Renewal Documents Required Letter from the client. No paid claims. Short period refund Change Request Form / from registered mail id Change Request Form/ from registered mail id Addition of Member Proposal Form from the Client, Premium payment. - midterm only in 3 scenarios -Other additions only at Renewal Proposal Form from the client, Premium payment Mid- term allowed for newly married spouse, newborn children after waiting period and child > 91 days not covered earlier Deletion of Member Policy Period change Corrections (Name, Gender etc) Address /Nominee change Contact Details Letter from the Client Letter from the Client Letter from the Client Letter from the Client Intimation from Client mid term only on death and divorce of member For other cases at Renewal Letter from the Client/ / from registered mail id /Death Certificate or Divorce certificate No paid claims. Pro-Rata refund Not - Change Request Form /Letter from the Client/ from registered mail id and other supporting documents Change Request Form /Letter from the Client/ from registered mail id and other supporting documents Change Request Form /Letter from the Client/ from registered mail id or on recorded call,

20 Change of DOB Letter from the Client Premium payment, Documentary evidence Change Request Form /Letter from the Client// from registered mail id Premium payment, Documentary evidence Note: Incase of any data entry error, intimation from client in any form will be accepted. 13 Glossary i) Insurable interest: Insurable interest exists when an insured person derives a financial or other kind of benefit from the continuous existence or well-being of the insured subject. A person has an insurable interest in something when loss-of or damage-to that thing would cause the person to suffer a financial or other kind of loss. E.g. Parents have insurable interest in their children, Husband has insurable interest in his wife and vice versa, etc. ii) Insurability: Insurability means whether a particular client can be insurable by an insurance company, because of the quality assigned pertaining to the risk that a given client would have. An individual with very low insurability may be said to be uninsurable, and an insurance company will refuse to issue a policy to such an applicant. iii) Indemnity: Refers to compensate another party to a contract to the extent of loss, which such other party may suffer during the performance of the contract. The financial loss has to be real and incurred. E.g. A (Insured) gets into indemnity health insurance contract with B (Insurer/Insurance Company), A would be compensated for lower of the incurred expenses or sum insured, by B in case of health expenses incurred during policy period as per contract terms & conditions. Suppose if A has policy with B for sum insured of Rs, and incurs medical expenses of Rs, he would get reimbursement of Rs. And if incurred expenses are beyond sum insured limits, say Rs he would get Rs. iv) Material fact: Is a fact whose expression/concealment would reasonably result in a different decision of entering into contract of insurance. The principle of utmost good faith requires anyone seeking insurance to disclose all the material facts about the risk that he knows, or should know. Right to decide if the given fact is material or not vests with insurer, and not the insured. Hence every fact pertaining to the risk needs to be disclosed to the insurer prior to the formation of insurance contract. E.g. Insured declaration of not suffering from diabetes when he actually is may result in policy issuance, instead of refusal of the policy if the fact would have been disclosed to the insurer beforehand. v) Nondisclosure: Failure or refusal to declare or reveal part or full information that is required to be declared or revealed. E.g. Non-disclosure of past medical history of diabetes, Non-disclosure of past medical history of diabetes with disclosure of past medical history of hypertension. vi) Misrepresentation: Means a false statement of fact made by one party to another party, which has the effect of inducing that party into the contract. E.g. Wrong date of birth provided to get categorized for medicals free issuance (Non-medical- Age & Sum insured basis) OR if falling outside entry age criterion of the product. vii) Exclusion: A cause of loss that is not covered by an insurance policy. viii) Earned income: Income ought to be earned by active participation in employment or self employment (Business) activity. E.g. Salaried class, Managing partner of the firm, Proprietor, etc. ix) Unearned income: Income which may continue even without active participation by its recipient. E.g. Rental income, Pension income, etc. x) Sum assured: is the fixed amount payable to the beneficiary on occurrence of insured event as per policy terms and conditions. E.g. Critical illness benefit, Term life insurance, etc.

21 xi) Sum insured: is the maximum liability of the insurer under an insurance policy to which extent incurred loss is payable, as per policy terms and conditions. E.g. Health insurance, Motor insurance, etc. xii) Morbidity: the rate of disease or proportion of diseased persons in a given locality, nation, etc. 14 Claim Procedure What do I do in case of a claim or any assistance? Intimation & Assistance Please contact us atleast 7 days prior to an event which might give rise to a claim. For any emergency situations, kindly contact us within 24 hours of the event. We can be contacted through: - Website : m - Toll Free : Fax : Courier : Claims Department, Apollo Munich Health insurance Co. Ltd Ground floor, Srinilaya Cyber Spazio Suite # 101,102,109 & 110, Ground Floor, Road No. 2, Banjara Hills, Hyderabad Or Claims Department Apollo Munich health insurance Co. Ltd. Plot No. 277, 2 nd floor, udyog vihar, phase iv Gurgaon , Haryana Please use the Claim Intimation Form for intimation of a claim. Procedure for Reimbursement of Medical Expenses We must be informed no later than 7 days of completion of such treatment, consultation or procedure. Please send the duly signed claim form and all the information/documents mentioned* therein to us within 15 days of the occurrence of the Incident. * Please refer to claim form for complete documentation. If there is any deficiency in the documents/information submitted by you, wewill send the deficiency letter within 7 days of receipt of the claim documents. On receipt of the complete set of claim documents, we will make the payment for the admissible amount, along with a settlement statement within -30 days. Thepayment will be made in the name of the proposer. Note: Payment will only be made for items covered under your policy and upto the limits therein. Procedure to avail Cashless facility For any emergency Hospitalisation, we must be informed no later than 24 hours after hospitalization. For any planned hospitalization, kindly seek cashless authorization from us atleast 48 hours prior to the hospitalization. We will check your coverage as per the eligibility and send an authorization letter to the provider. In case there is any deficiency in the documents sent, the same shall be communicated to the hospital within 6 hours of receipt of documents. Please pay the nonmedical and expenses not covered to the hospital prior to the discharge For details on non medical items, please refer to Annexure 2 of Policy Wordings. In case the ailment /treatment is not covered under the policy a rejection letter would be sent to the provider within 6 hours. Note: Insured person is entitled for cashless only in our empanelled hospitals. Please refer to the list of empanelled hospitals on our website Or the list provided in the guidebook or welcome

22 kit. Rejection of cashless in no way indicates rejection of the claim. Intimation & Assistance Please contact Us within 14 days of diagnosis of first occurrence of Critical Illness. - Website : - Toll Free : Fax : Courier : Claims Department, Apollo Munich Health insurance Co. Ltd Ground floor, Srinilaya Cyber Spazio Suite # 101,102,109 & 110, Ground Floor, Road No. 2, Banjara Hills, Hyderabad Or Claims Department Apollo Munich health insurance Co. Ltd. Plot No. 277, 2 nd floor, udyog vihar, phase iv Gurgaon , Haryana Please use the Claim Intimation Form for intimation of a claim. Claims Procedure Critical Illness You must intimate us within 14 days of diagnosis of first occurrence of Critical Illness. You must submit a duly filled claim form along with specified documents within 45 days of completion of survival period for the Critical Illness against which the claim is made. If there is any deficiency in the documents/information submitted by You, we will send the deficiency letter within 7 days of receipt of the claim documents. Any additional information requested must be submitted within 15 days of our request. On receipt of the complete set of claim documents, We will make the payment for the admissible amount, along with a settlement statement within 30 days. E-opinion Please submit duly filled claim form along with the copy of all medical reports including investigation reports and discharge summary (if any) at any of our Branch Office. You need to select Our Panel Doctor from whom You would prefer to take the e-opinion. (Please refer Our Website or call at 24X 7 Toll Free line to obtain the list of Our Panel Doctors) On receipt of the complete set of documents We will forward the same to the concerned doctor. The E-Opinion will be forwarded to the member within 7 working days of the receipt of the complete set of documents. For any doubt or clarifications and/or information, call our Toll Free Line at or log on to our website or us at customerservice@apollomunichinsurance.com

23 15 USP s of Easy Health Unique Features in Easy Health Features in some Competition s Products No Room Rent Capping Upto 1% of sum insured per day Upto Rs 1000 per day Room Type allowed- shared room No Sublimit on Pre/ Post Domiciliary Treatment Hospitalisation, Domiciliary covered upto 15% of Sum Treatment & Day Care Insured Procedures Upto Rs for Cataract No Claim Level underwriting and Loading 50% claims loading on renewal premium incase claim last year was between Rs100, ,000 and not pertaining to chronic illness 75% claims loading on renewal premium incase claim last year pertained to chronic illness Impact No restriction on room rent. Insured is free to choose his type room in hospital upto full sum insured No Sublimit on basic benefits. Insured is free to utilize his sum insured without any sublimit Premiums at renewal increase substantially if claim loading is applied to renewal premium, making it difficult for the customer when he needs it the most Lifelong Renewal Renewals allowed till age 70 Hassle free renewals. Once the policy is issued, Insured can renew the policy continuously for lifelong without any break in the policy No Copayment 20% copayment per claim for Insured above 65 years of age 20% copayment for non network hospitals No cost bearing by customer in claims till the time his sum insured is exhausted

24 16 Considerations for choosing right Sum Insured