FAQ s for Health Guard Policy

Transcription

1 FAQ s for Health Guard Policy Question: What is different in Health Guard Revised policy? Answer: Revised Health Guard policy is designed to suit all your health care needs. A comprehensive range of benefits, ensuring you are covered for the larger expenses related to Illness/surgery with a coverage s like sum insured reinstatement, convalescence benefit maternity expenses & many more Question: What are Sum Insured options in Health Guard Revised policy? Answer: There are two plans Silver & Gold in revised Health Guard policy & the sum insured are as per the plan opted. Silver Plan- Rs.1.5/2lacs Gold Plan - Rs.3/4/5/7.5/10/15/20/25/30/35/40/45/50 lacs Question: What is the Policy Period in revised Health Guard? Answer: Policy can be taken for 1year/2years or 3years Question: Is revised Health Guard an Individual or Floater policy? Answer: Policy provides Individual as well as Floater sum insured options under both plans Question: Which family members can be covered in revised Health Guard? Answer: Self, Spouse, Dependent Children, Grandchildren, Parents, Sister, Brother, Parent-In-laws (of the proposer), Aunt & Uncle of the proposer can be covered under individual option Self, Spouse, dependent children can be covered under floater option. For Parents & parent-in-laws separate floater policy can be taken. Question: Is there any Room Rent Capping in Health Guard Revised policy? Answer: Yes there is Room Rent capping in Silver Plan i.e. 1% of Sum Insured (excluding cumulative bonus) per day or actual, whichever is lower. However there is no such capping under Gold plan Question: How will the Room Rent Capping apply, will it be for Room rent only or for over claim amount? Answer: In case of admission in higher room category than eligible then the reimbursement of other expenses like consultation fees, OT charge, Anesthetist fees etc will be charged as per the eligible room rent hence it will apply on overall claim amount Question: Is there any capping for ICU charges as well? Answer: No there is no capping for ICU, the ICU charges will be paid as per the actuals under silver as well as gold plan

2 Question: What is the period for Pre & post hospitalization? Answer: Pre hospitalization is covered for 60 days & post is covered for 90 days Question: What is the Road Ambulance coverage in Health Guard Revised policy? Answer: Road Ambulance will be paid maximum of Rs 20000/- per policy year, whereas it existing Health Guard it was Rs 1000/- per valid hospitalization claim. Question: What is the limit of Day Care procedures? Answer: There is no limit for Day Care procedures, any procedure according to the definition of Day Care Center & Day Care Treatment can be covered. Question: Is Preventive health checkup available in Health Guard Revision? Answer: Yes, at the block of 3 years (irrespective of claims) Preventive health checkup is given but there is a difference in Silver & Gold Plan. Silver Plan - Individual Policy- 1% of the sum insured max up to Rs. 2000/- for each member Gold Plan - Individual Policy- 1% of the sum insured max up to Rs. 5000/- for each member (Floater Policy- Available for proposer & spouse only) Question: What are the new coverage benefits in Health Guard Revised policy as compared to existing Health Guard? Answer: Organ Donor Expenses, Convalescence Benefit, Daily Cash Benefit for Accompanying an Insured Child, Sum Insured Reinstatement Benefit, Ayurvedic / Homeopathic Hospitalization Expenses, Maternity Expenses, New Born Baby Cover, Bariatric Surgery Cover are newly added features in Revised Health Guard. Note - Ayurvedic / Homeopathic Hospitalization Expenses, Maternity Expenses, New Born Baby Cover, Bariatric Surgery Cover are only available in Gold Plan Question: What is Organ Donor expenses? Answer: This is a new addition of benefit in revised health Guard, it simply means that we will be covering the charges borne by insured person towards the treatment of the person who will be donating the organ to the insured person. The only condition is that the main claim of the insured person for which the organ is being donated is payable under the policy. Question: What is Convalescence Benefit? Answer: This is a new addition of benefit in revised health Guard, under this benefit we pay a lump sum amount to the insured if the admission is more than 10 days. We will pay benefit amount of Rs. 5,000 for Sum Insured up to Rs 5 lacs and Rs for Sum Insured 7.5 lacs and above per policy year provided the hospitalization claim is accepted.

3 Question: What is Daily Cash Benefit for Accompanying an Insured Child? Answer: Under the benefit we will pay Rs. 500 per for one parent/legal guardian to accompany the insured child who is under 12 yrs of age & is admitted in the hospital. The benefit is for maximum up to 10 days per policy period. Question: What is Sum Insured Reinstatement Benefit? Answer: In case if the sum insured along with the Cumulative Bonus, is exhausted due to claims made under the policy then up to 100% of the sum insured is reinstated for future claims at no extra premium. The difference here is that this reinstated Sum insured will be applicable for the illness, for which the claims are already made under the policy. The reinstated Sum Insured would be triggered only for subsequent claims made by the Insured Person. In case of relapse within 45 days, this benefit will not trigger. Example For policy period 1st Jan 2017 to 31st Dec 2017 Claims Details Claim 1 Claim 2 Claim 3 Sum Insured at beginning of policy year (Rs) Cumulative Bonus NA NA Total eligible Sum Insured limit applicable for the year Individual undergoes an inpatient hospitalization 1st claim 2nd claim 3rd claim Claim amount (Rs) Reinstatement benefit triggered No No Reinstateme nt Benefit will be triggered for this claim Claim paid amount (Rs) Additional Reinstated Sum Insured triggered (Rs) NA NA Balance Sum Insured (Rs)

4 Question: What is covered under Ayurvedic / Homeopathic Hospitalization Expenses? Answer: This benefit is available under Gold plan only, under this benefit we will pay maximum Rs /per policy year if the insured is Hospitalized due to an illness/injury in an Ayurvedic / Homeopathic Hospital (Government hospital or in any institute recognized by government and/or accredited by Quality Council of India/National Accreditation Board). Question: How is the Maternity benefit paid in Revised Health Guard? Answer: Maternity benefit is part of Gold Plan only & is paid as below. The waiting period is of 72 months and it not mandatory for self & spouse to complete the waiting periods in the same or different policy. For Sum Insured 3 lac to 7.5 lacs Normal delivery- Rs /- Caesarean section- Rs /- For Sum Insured 10 lacs to Rs. 50 lacs Normal delivery- Rs /- Caesarean section- Rs /- Question: Is the waiting period for Maternity benefit applicable for portability and renewal cases of existing Health Guard Policies? Answer: Yes, fresh waiting period of 72 months would apply afresh for all the policies which are issued with continuity under portability guidelines & from existing Health Guard Policies. Question: Is New Born Baby Covered in revised Health Guard? Answer: Yes new born baby expenses including mandatory vaccination up to 90 days are covered under Maternity sum insured in Gold plan. Question: What is Bariatric Surgery Cover? Answer: This is only available under Gold plan. Bariatric surgery is a surgery on the stomach and/or intestines to help a person with extreme obesity lose weight. However under the Health Guard policy this surgery will be covered for insured age 18 yrs & above with documented obesity & BMI greater than or equal to 40 with any of the following conditions- 1. Coronary heart disease 2. Blood pressure greater than 140 mm Hg systolic and/or 90 mm Hg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes) 3. Type 2 diabetes mellitus

5 Question: Is there any restriction of sum insured/ waiting periods for Bariatric Surgery Cover? Answer: Yes the waiting period is for 36 months & the sum insured is restricted to 50% of Sum insured maximum up to Rs. 5 lac. Waiting period of 36 months would apply afresh for all the policies which are issued with continuity under portability guidelines & from existing Health Guard Policies Question: Is it mandatory or is it advisable to seek prior approval from Insurance Company regarding bariatric surgery? Answer: Yes it is mandatory for the insured person to take prior approval for cashless treatment from the Company. Question: Is the sum insured under all sections a part of the base sum insured Answer: No, sum insured payable under maternity, convalescence benefit & daily cash benefit for accompanying insured child is over & above the base sum insured. Sum Insured for rest all sections are a part of the base sum insured only Question: Is there any change in Cumulative Bonus in Revised Health Guard? Answer: Yes, Cumulative bonus is the 10% of base sum insured per claim free year maximum 100% whereas it was maximum 50% in existing Health Guard. The same will also decrease by 10% in a year where claim is paid. Question: will the Cumulative Bonus passed from existing Health Guard to Revised health Guard at renewal? Answer: Yes the cumulative bonus will be passed from existing Health Guard to Revised health Guard. In case of 50% CB in existing Health Guard & the previous year being claim free, the CB in the current year will remain 50%, however next year on renewal if there is no claim on the policy it will increase by 10% & become 60%. Question: How will cumulative bonus be calculated in long term policies? Answer: Cumulative bonus will be calculated on annual basis for long term polices same will reflect on the renewal notice Question: Is medical test applicable in the revised Health Guard? Answer: No Medical tests up to 45 years, subject to no adverse health conditions. Medical tests (prepolicy checkup) are mandatory for members above 45 years of age

6 Question: will there be medicals for person s renewal in revised health Guard from existing Health Guard? Answer: Medical tests will not be asked for at renewals if the renewal is as per exiting terms & conditions. Question: Are there any Sub-limits in revised Health Guard? Answer: Yes there are sub limits For Health Guard Silver Plan Room rent restricted to max 1% per day of Sum Insured opted Cataract Limit per eye 20% of Sum Insured For Health Guard Gold Plan Cataract Limit per eye 20% of Sum Insured max up to Rs. 1lac Bariatric Surgery restricted to 50% of the Sum insured, subject to maximum of Rs 5 lac. Maternity Expenses- From Sum insured Rs. 3lacs to Rs. 7.5lacs it is restricted to Rs for normal delivery and Rs for caesarean section and from Sum insured Rs. 10lacs to Rs. 50lacs it is restricted to Rs for normal delivery and Rs for caesarean section Question: For cataract will we include sum insured &cumulative bonus? Answer: Yes, the cataract limit is applicable on base sum insured plus cumulative bonus. For e.g. sum insured is & CB is 20% i.e. Rs so max limit for cataract will be Rs.48000/eye Question: Can I enhance my sum insured at Renewal under Revised Health Guard? Answer: Yes you can enhance your sum insured, in case of claim or any health declaration the enhancement will be accepted subject to underwriting approval Question: Are there any discounts under the revised Health Guard? Answer: Yes there are discounts under the revised Health Guard and some are new addition w.r.t existing Health Guard Discounts 1. Family Discount- 10% if 2 eligible family members are covered under a single policy 15% if more than 2 of any of the eligible family members are covered under a single policy Note- Family discount is not applicable to Health Guard Floater Policies 2. Co pay Discount Co-pay Discount: If opted voluntarily

7 10% discount on the policy premium 20% discount on the policy premium 3. Employee Discount: 20% discount on published premium rates to employees of Bajaj Allianz & its group companies, this discount is applicable only if the policy is booked in 0 IMD code 4. Long Term Policy Discount- 4 % discount is applicable if policy is opted for 2 years 8 % discount is applicable if policy is opted for 3 years Question: What is maximum Renewal age under the policy? Answer: Renewal is for Lifetime. For Dependent Children/ Grand Children- Renewal in same policy is up to 35 years. Question: Is there any non-network Co pay in the revised health Guard? Answer: No there is no non-network Co pay in the revised health Guard Question: Is there any sum insured restriction or co-payment above 56 years in the revised health Guard? Answer: No there is no sum insured restriction or co-payment above 56 years in the revised health Guard Question: How is the premium charged under revised Health Guard? Answer: The premium is based on zone (zone is calculated as per PIN code of the policy holder s address). There are two zones Zone A & Zone B Zone A - Delhi / NCR, Mumbai including Navi Mumbai, Thane and Kalyan, Hyderabad and Secunderabad, Bangalore, Kolkata, Ahmedabad, Vadodara and Surat. Zone B - Rest of India apart from Zone A cities are classified as Zone B Question: Is there any impact on claim for zone A & B? Answer: Yes, Policyholders paying Zone A premium rates can avail treatment allover India without any co- payment. But, those who pay zone B premium rates and avail treatment in Zone A city will have to pay 20% copayment on admissible claim amount. This Co payment will not be applicable for Accidental Hospitalization cases. Policyholder residing in Zone B can choose to pay premium for Zone A and avail treatment all over India without any co-payment

8 Example- A person residing in Mumbai (which is in Zone A) & pays premium for Mumbai can take treatment anywhere in India without any Co-payment. But if a person residing in Pune (which is in Zone B) takes a policy with premium of Pune, but takes treatment in Mumbai then he would have to bear a Co pay of 20%. However the person residing in Pune has the option to buy the policy of zone A by paying the premium of Zone A & can take treatment anywhere in India. Question: Is there any difference in waiting periods under revised Health Guard? Answer: Yes there is difference in waiting periods 1. Pre-existing conditions will be covered after 36 months as compared to 48 months in existing Health Guard 2. Specific disease like- Cataracts, Hernia of all types, Fistulae, Fissure in ano, Hysterectomy etc will be covered after 24 months (remains the same as existing Health Guard) 3. Joint replacement surgery, Surgery for prolapsed inter vertebral disc (unless necessitated due to an accident, Surgery to correct deviated nasal septum, Hypertrophied turbinate, Congenital internal diseases or anomalies & Treatment for correction of eye sight due to refractive error recommended by Ophthalmologist for medical reasons covered after 36 months - as compared to 48 months in existing Health Guard Question: Are costs of medical test reimbursed if I undergo medical tests? Answer: Yes, 100 % cost of pre-policy checkup would be refunded if the proposal is accepted & policy is issued Question: Does revised Health Guard cover OPD expenses as well? Answer: No. OPD is not covered under revised Health Guard Question: Is only the first maternity claim paid, or there is no such restriction? Answer: Maternity claim is paid for maximum 2 deliveries or terminations (medically recommended and lawful termination of pregnancy) Question: How will the premium be calculated for long term policies & how will discounts apply? Answer: Premiums will be calculated a below- Base Premium For 1 year Multiplied by 3 -for 3 years Premium Less Family Discount@15% Less Co Pay discount@10% Employee discount@20% Less long Term Discount@8% Add S Tax@15% Final Premium (inclusive of S 15%)

9 Question: Will we offer Revised HG under Health Guard section of Star Package policy as well? Answer: No, the Health Guard section under Star Package remains unchanged Question: Can we choose separate plans and separate sum insured for different family members under IHG? Answer: Yes, one choose separate plans and separate sum insured for different family members provided the sum insured of self is higher than dependents. Question: Can I continue with the existing Health Guard & buy a revised Health Guard also? Answer: No, Once the product is launched then the new business will be booked in revised health Guard only. The renewals where the renewal notices have been received by client with existing Health Guard will have the option to renew in existing Health Guard and the same will continue till next renewal. At the next year renewal the client will have to renew the policy in revised Health Guard only. Question: If the age of dependent child is crossing the limit of 35 years during long term policy then will we cover the child in same policy or he will have to move to separate policy? Answer: The child will be covered in the same policy even if he crosses the dependent age limit of 35 years mid-term, at the next renewal however the child will have to take separate policy as proposer.