DO YOU KNOW?
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AVERAGE HOSPITALISATION COST (INDIA) Source NSSO survey 2014 4
crore people are pushed towards poverty every year because of treatment bills out of every 1,000 Indians reporting of ailment in urban sector end up getting hospitalized in a year. As per WHO percentage of Indians pay for medical expenses out of the pocket http://www.thehindu.com/news/national/quality-healthcare-system-needed-for-poor-rich-alike-pranab/article4002525.ece http://apps.who.int/medicinedocs/en/d/js19109en/. 5
Average Medical Expenditure per Day (Rs) 16,046 International Federation of Health Plans http://www.indiamedicaltimes.com/2012/03/05/a-hospital-stay-costs-236-per-day-in-india-vs-3949-per-day-in-the-us-study/ 6
Our Product Offering Group Assurance Health Plan
Sum Insured (Rs.) 1,000,000 750,000 500,000 300,000 200,000
Eligibility Criteria Age at entry (Min) Age at entry (Max) Self 18 years 69 years Adult Dependent 18 years 69 years Child Dependent 91 days 25 years There is no cover ceasing age on continuous renewals Family definition include self, spouse, upto 3 dependent children and either set of dependent parents or parents in laws AMHI CONFIDENTIAL 18 July 2017 9
Plan Structure Individual sum insured Family floater sum insured 10
Plan Types Individual Plan Covers self, spouse and upto 3 dependent child, coverage would be on Individual Sum Insured basis. Family Plan 2 Adults Covers self and spouse. Policy will have the same Sum Insured for both the members and coverage would be on floater basis. Family Plan 2 Adults + 3 Children Covers self, spouse and upto 3 dependent children. Policy will have the same Sum Insured for all the members and coverage would be on floater basis Parents Plan Covers either set of dependent Parents or parent s in law on both individual or family floater basis 11
Quiz?
Let s Begin? 1. What is the Minimum and Maximum Sum Insured? 2. What is the Minimum and Maximum Entry Age? 3. What is the cover ceasing Age in the policy? 4. How many adults can be included in Floater plan?
Product Benefits Benefits In-patient hospitalisation Pre-hospitalisation Post-hospitalisation Day care procedures Domiciliary Treatment Organ Donor Ayush Benefit Restore Benefit Sum Insured Upto Sum Insured 60 days 90 days 182 listed day care procedures Upto Sum Insured Upto Sum Insured Upto Sum Insured Upto Sum Insured Preventive Health Check-up At each renewal upto 1% of sum insured; subject to max Rs 5000 Emergency Ambulance Hospital Daily Cash Rs. 2000/- per hospitalisation 1000 per day maximum 15 days
In-patient Hospitalisation Medical expenses for- Room rent, boarding expenses, Nursing, Intensive care unit, Medical practitioner(s), Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, Medicines, drugs and consumables, Diagnostic procedures, The cost of prosthetic and other devices or equipment if implanted internally during a surgical procedure.
Pre & Post Hospitalisation Medical expenses incurred for consultations, investigations and medicines Pre Hospitalisation upto 60 days immediately before the insured person was hospitalised Post- Hospitalisation upto 90 days immediately after the insured person was discharged from hospital Provided that Such costs are incurred in respect of the same condition for which the insured person s earlier hospitalisation was required, and We have accepted an in-patient hospitalisation claim under In-patient treatment.
Domiciliary Treatment Medical treatment for an Illness/disease/injury which in the normal course would require care and treatment at a Hospital but is actually taken while confined at home under any of the following circumstances: The condition of the patient is such that he/she is not in a condition to be removed to a Hospital or, The patient takes treatment at home on account of non availability of room in a Hospital Pre Hospitalisation expenses for consultations, investigations and medicines incurred upto 30 days before hospitalisation Benefit excludes Treatment of less than 3 days. Expenses for treatment for first three days only will be covered if treatment period is greater than 3 days) Post-Hospitalisation expenses
Daycare Treatment Medical treatment or surgical procedure which is undertaken under general or local anaesthesia, which require admission in a Hospital/Day Care Centre for stay less than 24 hours because of technological advancement. Treatment normally taken on out-patient basis is not included in the scope of this definition. Please refer List of Day Care Treatments/Procedures is annexure 1 Benefit excludes Treatment that can be and is usually taken on an out-patient basis is not covered. Treatment NOT taken at a Hospital or a Day Care centre. Note: Pre & Post hospitalization expenses are covered under Day Care Procedures also
Organ Donor Medical and surgical Expenses of the organ donor for harvesting the organ where an Insured Person is the recipient. Benefit excludes Claims which have NOT been admitted under 1a) for the insured person. Admission not compliant under the Transplantation of Human Organs Act, 1994 (as amended). The organ donor s Pre and Post-Hospitalisation expenses.
AYUSH Benefit Medical expenses incurred for in-patient treatment taken under Ayurveda, Unani, Sidha or Homeopathy provided that the treatment has been undergone in Government hospital or in any institute recognized by government and/or accredited by Quality Council of India or National Accreditation Board on Health; or Teaching hospitals of AYUSH colleges recognised by Central Council of Indian Medicine (CCIM) and Central Council of Homeopathy (CCH); or AYUSH Hospitals having registration with a Government authority under appropriate Act in the State/UT and complies with the following as minimum criteria has at least fifteen in-patient beds; has minimum five qualified and registered AYUSH doctors; has qualified paramedical staff under its employment round the clock; has dedicated AYUSH therapy sections; maintains daily records of patients and makes these accessible to the insurance company s authorized personnel
Restore Benefit If the base Sum Insured is exhausted during the policy period then Restore Sum Insured (equal to 100% of the Base Sum Insured) will be automatically reinstated for that policy period, provided that: The Restore Sum Insured will be triggered only after the Base Sum Insured have been completely exhausted The Restore Sum Insured can be used for claims made by the Insured Person in respect of the benefits stated in-patient cover The Restore Sum Insured can be used for only future claims made by the Insured Person and not against any claim for an illness/disease (including its complications) for which a claim has been paid in the current Policy Year The Restore Sum Insured will only be applied once for the Insured Person during a Policy Year; If the Restore Sum Insured is not utilised in a Policy Year, it shall not be carried forward to any subsequent Policy Year. If the Policy is a Family Floater, then the Restore Sum Insured will be available for all Insured Person in the Policy for subsequent claims in the balance Policy period.
Ambulance Cover Expenses incurred on transportation of insured person to a hospital for treatment in case of an emergency, subject to Rs. 2000 per hospitalisation.
Mr.Natwarlal having 5 lacs Health Insurance Policy. He is hospitalised for 10 days and hospitalisation expenses amounted Rs.1,20,000/- How much any company will pay? Rs.1,20,000/- only But, AMHI will pay Rs.1,20,000/- + Rs.10,000/- = Rs.1,30,000/-
Hospital Daily Cash In case of in-patient hospitalisation due to illness or accident a daily cash amount shall be provided for each continuous and completed period of 24 hours Provide over and above base sum insured limit Daily Cash per Day (Rs) 1000 15 days Maximum days in a policy year
Preventive Health Check-up Reimbursement of expenses incurred on a preventive a health check up. Benefit can be availed only once during the renewed policy period. Health check-up limited is over and above the base sum insured limit. This benefit is available ONLY to those Insured Persons who were insured in the previous policy. Individual sum insured Upto 1% of sum insured per insured person subject to maximum of Rs 5000 Family Floater sum insured Upto 1% of Sum Insured per policy subject to maximum of Rs 5000 Preventive Health Check-up means a package of medical test(s) undertaken for general assessment of health status, it does not include any diagnostic or investigative medical tests for evaluation of illness or a disease.
Procedure for Health Check-up reimbursement Step 1: Please submit a copy of all health checkup reports along with original bills at any of Apollo Munich Branch Office. Step 2: If there is any deficiency in the documents/information submitted by you, the AMHI will send the deficiency letter within 7 days of receipt of the claim documents. Step 3: Step 4: On receipt of the complete set of claim documents, AMHI will process the admissible amount, along with a settlement statement within 15 days. Reimbursement amount will be credited into insured s account via NEFT.
Quiz?
Let s Begin? 1. How many days are covered in Pre & Post Hospitalisation? 2. How many Daycare treatments are covered? 3. How much Daily Cash benefit is paid per day? 4. When will Restore benefit trigger? 5. Health check up benefit can be claimed after?
Waiting Periods 30 Days Any treatment or admission within first 30 days of policy inception except any accidental injury. Specified Illness 24 months waiting period for specific diseases like Cataract, surgery for hernia, surgery for hydrocele etc. Pre-existing Diseases Pre-existing diseases (PED) waiting period of 48 months
General Exclusions Expenses arising from HIV or AIDS and related diseases Internal congenital diseases, mental disorder or insanity, cosmetic surgery and weight control treatments Expense attributable directly or indirectly to pregnancy (including voluntary termination), miscarriage (except as a result of an Accident or Illness), Abuse of intoxicant or hallucinogenic substances like intoxicating drugs and alcohol Drugs or treatments which are not supported by a prescription Hospitalization due to war or an act of war or due to a nuclear, chemical or biological weapon and radiation of any kind Pregnancy, dental treatment, external aids and appliances Items of personal comfort and convenience Experimental, investigative and unproven treatment devices and pharmacological regimens. Plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment. Please refer to the Policy Wording for the complete list of exclusions.
Group Personal Accident
Road Accidental death by different modes
Group Personal Accident (Inbuilt)
Group Personal Accident Cover equivalent to base health sum insured for each insured member under individual plan and for primary insured member under family floater plan. Personal accident cover not provided under parent s plan Benefits Accidental Death Permanent Total Disablement Features Sum Insured equal to base health sum insured 100% of Accidental Death Sum Insured Emergency Ambulance Upto Rs 2000/- Transportation of mortal remains 2 % of accidental sum insured; maximum up to Rs 10,000
Product Benefits Accidental Death : Insured person suffers an accident during the policy period and this is the sole and direct cause of his death within 365 days from the date of the accident, then we will pay the sum insured Transportation of Mortal Remains : In case of accidental death, reimbursement upto Rs. 1000/- for expenses incurred in transporting the mortal remains of the insured person from the place of the accident or the hospital to his residence or hospital or to a cremation or burial ground. Emergency Ambulance Cover - Actual expenses upto Sum insured, incurred on an ambulance used to transfer the Insured Person to the nearest Hospital by the shortest route following an emergency caused due to an Accident Permanent Total Disablement: Lumpsum payment in case of a permanent total disablement as per scale below Type of cover % of Sum Insured Loss of 2 Limbs (both hands or both feet or one hand and one foot) 100% Loss of a Limb and an eye 100% Complete and irrecoverable loss of sight of both eyes 100% Complete and irrecoverable loss of speech & hearing of both ears 100% Loss of a Limb 50% Complete and irrecoverable loss of sight of an eye 50%
General Exclusions Any Pre-existing Condition or any complication arising from the same. Intentional self injury, suicide or attempted suicide, while sane or insane. Any psychiatric or mental disorders. AIDS (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human immunodeficiency virus), venereal disease, sexually transmitted disease or illness, Any Insured Person s participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing. Arising or resulting from the insured person(s) committing any breach of law with criminal intent. The abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and alcohol. War or any act of war, invasion, act of foreign enemy, war like operations (whether war be declared or not or caused during service in the armed forces of any country), civil war, public defense, rebellion, revolution, insurrection, military or usurped acts, chemical, radioactive or nuclear contamination. Please refer to the Policy Wording for the complete list of exclusions.
Cancellation (on insured s request) If no claim has been made Short scale If claim has been reported, rejected or settled No refund Please refer to annexure 2 for short scale grid 38
Tax Benefit As per Section 80D An assesse is entitled to a deduction of Rs. 25,000 in respect of medical premium paid on the health of himself, his spouse and children. If any of them is a senior citizen, then he shall be entitled to a maximum deduction of Rs. 30,000 as a whole. In addition if he pays insurance premium on the health of his parents, whether dependent or not, he will be entitled to additional deduction of Rs. 30,000
Guidelines
Good Health Declaration Please read, understand and confirm Health Details accurately and truthfully in the space mentioned below, since this would be the ONLY basis of issuance of your policy with us and the subsequent claim admissibility if any. If your answer to any or all of the following 12 health statement/s is YES, then you are advised NOT to sign this Enrolment form or pay any premium as you are not eligible to take this policy. Any mis-declaration or non-disclosure here will render your coverage null and void Taken any medicine more than 21 days consistently except for infrequent acidity, loose motion, common cold, fever, headache; high cholesterol, asthma, diabetes, hypertension and hyperthyroidism. Y N Any disease of major organs including but not limited to brain (includes stroke or paralysis), heart, kidney, lungs, liver or mental health disorder. Y N Any complications related to Diabetes, Hypertension, and Hypothyroidism like but not limited to problems related to heart, eye, kidney, numbness and tingling in hand and feet, stroke, gangrene of foot Y N Any problem with vision or eyes in last 10 years, other than having undergone cataract operation in either or both eyes, or having errors of refraction. Y N Any stone of the kidney, ureter or bladder diagnosed or operated in the past 10 years Y N Any problem with reproductive organs like prostate, testis (Applicable for males). Y N Undergone any surgery other than appendicectomy / cholecystomy /hysterectomy, minor fracture surgeries or surgeries for family planning/ C- section (Applicable for Females) or have been hospitalized for greater than 10 continuous days in last 5 years. Y N Any disorder of the cervix, uterus, ovary (ies), abnormal bleeding or problem with reproductive system. (Applicable for females) Y N Any history of spinal or joint disorders like but not limited to arthritis, slip disc ( prolapsed intervertebral disc) in the past 5 years. Y N Tumor or Cancer anywhere in the body. Y N Ever reported positive for Hepatitis B, HIV / AIDS or other sexually transmitted disease. Y N Are you or any of the members proposed to be insured under this policy awaiting any treatment, medical/ surgical or attending any follow up for any Y N I hereby disease declare / condition and warrant / ailment/ on my injury behalf /addiction. and behalf of all persons proposed to be insured that the above statements are true and complete in all respects. I agree that this declaration shall be the basis of the decision by Apollo Munich Health Insurance Company Ltd to cover or not cover us under insurance. Yes, I confirm No, I can t confirm
Who can confirm Good Health Declaration Who can confirm good health and is eligible to get the policy? Healthy Individuals (No disease, disability, illness, disorder or symptom ever) Individuals with Diabetes, Hypertension and/or Hypothyroidism without any complications (free from other diseases unless specified in GHD) Individuals who have not taken any medicine for consecutive 21 days in last 5 years (except for infrequent acidity, loose motions, common cold, fever, headache, high cholesterol, asthma, hypothyroidism, hypertension and diabetes) Individuals who have NOT suffered from any stone disease like kidney, ureter or bladder stones in the last 10 years
Premium
Premium inclusive of 18% Goods and Service Tax (Rs.) Individual Plan You can cover yourself, your spouse and upto 3 dependent child under this plan, coverage would be on Individual Sum Insured basis. Age bands 200,000 300,000 500,000 750,000 1,000,000 0-45 2,688 3,313 4,554 5,505 6,276 Above 45 4,086 4,996 7,062 9,038 10,422 Family Floater (2 Adults) - You can cover yourself and your spouse under this plan. A family floater policy will have the same Sum Insured for all the members and coverage would be on floater basis. Age bands 200,000 300,000 500,000 750,000 1,000,000 0-45 4,693 5,893 8,067 9,772 11,154 Above 45 6,321 7,637 10,649 13,154 15,113 Family Floater (2 Adults + 3 Children) - You can cover yourself, your spouse and upto 3 dependent children under this plan. A family floater policy will have the same Sum Insured for all the members and coverage would be on floater basis. Age bands 200,000 300,000 500,000 750,000 1,000,000 0-45 6,344 7,795 10,445 12,746 14,575 Above 46 8,033 9,806 13,111 16,173 18,549
Premium inclusive of 18% Good & Service tax (Rs.) Parent s Plan You can cover either set of parents or parent s in law under this plan. Individual Coverage would be on Individual Sum Insured basis. Age bands 200,000 300,000 500,000 750,000 1,000,000 0-45 2,532 3,086 4,184 4,958 5,552 Above 46 3,930 4,769 6,692 8,491 9,698 Family Floater This policy will have same Sum Insured for both the members and coverage would be on floater. Age bands 200,000 300,000 500,000 750,000 1,000,000 0-45 4,537 5,665 7,697 9,225 10,430 Above 46 6,165 7,609 10,279 12,607 14,389
Claims Process
Claim Type Network Hospital Cashless settlement Hospitalisation Non Network Hospital Only Re-imbursement 47
Claim Intimation Fax / Email / Call / Letter Apollo Munich Intimation Acknowledgement Emergency Hospitalization (As soon as Possible) Planned Hospitalization (7 days prior to Admission) 48
Contact Details Hyderabad Hub & Gurgaon Hub Toll Free - 1800-102-0333 Fax - 1800-425-4077 E-mail- denacare@apollomunichinsurance.com Address : Hyderabad Hub Claims Department Apollo Munich Health Insurance Co Ltd. Ground Floor, Srinilaya Cyber Spazio Road No. 2, Banjara Hills Hyderabad-500034 Address : Gurgaon Hub Claims Department Apollo Munich Health Insurance Co Ltd. Central Processing Center2nd & 3rd Floor, ilabs Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurgaon- 122016, Haryana
Service Standard - Claims Particulars Preauthorization Query Rejection Claim reimbursement 2 Hrs 5 days 7 days 30 days TAT
Policy Issuance Process
Policy Issuance Process - Offline Pre-numbered enrolment forms would be available at Dena Bank branches and interested customer shall fill the Enrolment form which shall be duly signed by them. Enrolment form would be scanned uploaded by Dena Bank in the application provided The Enrolment form will then be scrutinized basis the guidelines provided Post scrutiny the cases will be either accepted or rejected. Accepted cases move in for data entry. Consolidated Remittance file with premium will be shared by Dena Bank For all eligible cases COI and E-card shall be generated, printed and dispatched For customers who have email ID & opt for Go Green option only soft copy of the policy will be issued. In cases where there is no Email ID the hard copy shall be sent
Policy Kit Content Certificate of Insurance Premium Receipt E-Card Hospital Network List Terms and Conditions Coverages Exclusions Claim Procedures Contact Details Grievance redresssal System generated enrolment form Delivery Hard copy of policy sent by courier Soft copy sent by e-mail where Go- Green opted TAT for policy issuance - T+2 (T being payment receipt date for accepted cases) 53
Contact Centre For any query related to policy servicing you can contact us at Toll free: 1800 102 0333 Email denacare@apollomunichinsurance.com Website: www.apollomunichinsurance.com Fax: 1800 425 4077
High sum insured options Personal Accident Restore Benefit Product USP s No co-pay or sublimits AYUSH Benefit Preventive Health Check up
Thank You!!
SPOC for Dena Bank Megha 8411 831007
Annexure 2 Short scale cancellation grid Length of time Policy in force % of premium refunded Upto 1 Month 75.00% Upto 3 Months 50.00% Upto 6 Months 25.00% Exceeding 6 Months Nil