religare pptfrfr

8/6/2019 religare pptfrfr

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AEGON Religare Health Plan


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Cus tomer s concern area s

Will I get my claims in full? Premium increases heavily in caseof a claim


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T here is no guarantee of claimsbeing paid

All surgeries are not covered


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24 hours hospitalisationrequired for surgery


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A s olu tion to c us tomer s concern s?


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M ajor co s t component s du ring ho s pitali s ationRoom charges

ICU charges

Cost of medicine

Cost of surgery


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Key construct of the PlanT he policyholder gets paid under the following scenarios:

Daily cashbenefit

DailyhospitalisationCash Benefit

Benefit paid for

every24

hoursstay in hospital

Intensive CareUnit Benefit

Benefit paid ifadmitted formore than 8hours & DHCB ispayable

10 key illnesses

are covered

Critical IllnessBenefit

Depending on

severity, aredivided in 6categories

Surgical CashBenefit


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D aily Ho s pitali s ation C as h Benefit ( D HC B)T his benefit will be:

Paid if the insured is hospitalised for a continuous period of 24 hours ormore

Paid on a daily basis

Available for maximum of 60 days in a policy yearT he benefit amount is fixed and does not depend upon the actual amount spent

T he benefit amount is as per the grid below:

Benefit Silver Gold Diamond Platinum

DHCB (Rs.) 2 ,000 3,000 4 ,000 5,000


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I nten s ive C are Unit Benefit ( I C UB)T his benefit will be:

Paid if the insured is admitted in ICU for a period of 8 hours ormore and is eligible for DHCB

Paid on a daily basis

Available for maximum of 60 day in a policy year ( T he limit of60 day is combined for DHCB & ICUB)

T he benefit amount is fixed and does not depend upon the actualamount spent

T he benefit amount is as per the grid below:


ICUB (Rs.) 2 ,000 3,000 4 ,000 5,000


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An sw er thi s!

Sameer has bought the Silver plan under our Health policy.

A couple of years later, he is hospitalised for a period of 30days out of which 10 days were in ICU.

What is the benefit payable to Sameer?

2 ,000 * 30 = 60,000 (DHCB) + 2 ,000 * 10 = 2 0,000 (ICUB)

Remaining days eligible for the payout is 30 days

T herefore the total benefit will be Rs.80,000


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An sw er thi s!

Karuna has bought the Gold Plan under our Health policy.

She is hospitalised for a period of 60 days in ICU.

What is the benefit payable to Karuna?

3,000 * 60 = 1,80,000 (DHCB) + 3,000 * 60 = 1,80,000 (ICUB)

T herefore the total benefit will be Rs. 3,60,000

Total annual limit has been used


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S u rgical C as h BenefitT his benefit will be paid if the insured undergoes any of the surgeries defined inthe list

Surgeries are classified into 6 categories, basis their severity and the average costof surgery

Minimum hospitalisation of 24 hours is not required to claim this benefit

Some surgeries have a specific waiting periodT he benefit amount is fixed and does not depend upon the actual amount spent

Minimum hospitalisation of 24 hours is required if the life insured undergoes asurgery under category 6


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S u rgical C as h BenefitC ategory of Surgery Silver Gold Diamond Platinum

Category 1 2 00,000 300,000 4 00,000 500,000

Category 2 150,000 22 5,000 300,000 375,000

Category 3 80,000 1 2 0,000 160,000 2 00,000

Category 4 4 0,000 60,000 80,000 100,000

Category 5 2 0,000 30,000 4 0,000 50,000

Category 6 (OSB) 10,000 15,000 2 0,000 2 5,000

Annual Limit 200,000 300,000 400,000 500,000

Lifetime Limit 1,000,000 1,500,000 2,000,000 2,500,000


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S u rgerie s covered s ome example s

T he defined list has 8 49 surgeries , out of which 241 are day care surgeries .

Surgeries from Category 1 to 5 do not require 24 hours admission

C ategory Surgery

Category 1 Heart Transplantation; Coronary Artery Bypass Graft

Category 2 T otal ankle joint replacement; Transluminal Coronary Angioplasty

Category 3 Repair of small artery injury; Craniotomy to treat epilepsyCategory 4 Arthrodesis of ankle joint; Repair of injury to Kidney

Category 5 Adenoidectomy; Endoscopic Biopsy of Prostate

Category 6 All surgeries not covered under Category 1 to 5 and carried outalong with 24 hours hospitalisation


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An sw er thi s!

Latish is covered under the Diamond Plan of our Health policy.

He undergoes a day care surgery in July which falls undercategory 4 . In the same policy year, Latish had earlierundergone one more surgery falling under category 1.

What is the amount of benefit payable to Latish for the Julysurgery?

Benefit amount paid for surgery of category 4 = Rs. 4 0,000

Benefit amount paid for surgery of category 1 = Rs. 3,60,000 as the annual limit is R s.4 ,00,000 out of which Rs. 4 0,000 was paid earlier


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An sw er thi s!

Manju is insured under our Silver Plan.

She undergoes a surgery which falls under category 1. Prior tothis surgery, Manju was admitted in the hospital for 10 daysour of which 2 days were in the ICU.

What is the total amount of benefit payable to Manju?

Manju is eligible to receive the following benefits:SCB = Rs. 2 ,00,000

DHCB (R

s.2

,000 * 10) =R

s.2

0,000ICUB (Rs. 2 ,000 * 2 ) = Rs. 4 ,000

Total benefit amount payable to Manju will be Rs. 2 , 24 ,000


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Benefit s u nder C ritical I llne ssCritical Illness benefit will not be available to children (below 18 years)

Benefit under this clause can be claimed once during the whole policy tenure

Survival period of 30 days from the date of diagnosis is necessary to avail thisbenefit

T he benefit is paid as under:


ICUB (Rs.) 50,000 75,000 1,00,000 1, 2 5,000


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Critical Illnesses Covered

1. Coma

2 . Stroke

3. Cancer

4 . Paralysis

5. Blindness

6. Alzheimers disease

7. Kidney failure

8. Aplastic Anaemia9. Muscular dystrophy

10. Cardiomyopathy


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An sw er thi s!

Kanchan has opted for our Platinum Plan and she undergoes asurgery under category 1. T his requires her to stay in the ICUfor 60 days. She is also diagnosed with a CI which is coveredunder our Health Plan.

In this case, what will be the total benefit payable toKanchan?

Kanchan is eligible to receive the following benefits:SCB = Rs. 5,00,000

DHCB (R

s. 5,000 * 60) + ICUB (R

s. 5,000 * 60) =R

s. 6,00,000CI Benefit = Rs. 1, 2 5,000

Total benefit amount payable to Kanchan will be Rs. 1 2 , 2 5,000


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Choose your Plan

Silver

Gold

Diamond

Platinum


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C omprehen s ive Benefit S tr u ctu reT he total benefit structure as per the plan will be as below:


DHCB 12 0,000 180,000 24 0,000 300,000

ICUB 12 0,000 180,000 24 0,000 300,000

SCB 2 00,000 300,000 4 00,000 500,000

CIB 50,000 75000 100,000 1 2 5,000

Total 490,000 735,000 9 8 0,000 1,225,000

T he table above shows maximum benefit that is available under the plan

Total benefit amount is the amount that can be paid in a policy years i.e.(DHCB + ICUB + SCB + CIB)

Policyholder can make multiples claims, subject to annual & lifetime limit


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Ho w is it su perior to M ediclaim ?


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Gu aranteed claim payment

Depending on the type of planchosen, a fixed amount ofmoney is paid. T his amount isguaranteed


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Higher payo u t even if claim i s lo w er

T he fixed amount is paid,irrespective of the actual billamount. So, suppose the

insured has a Diamond plan andunderwent a category 1 surgeryand cost of which was Rs.3,00,000. As per our plan theinsured will still get Rs.

4 ,00,000 towards the cost ofsurgery


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Payo u t in addition to other plan s

T he insured can claim this amountin addition to other medical policiesas we require only photocopies of

the bill. T his is a big advantage overmediclaim policies, where one hasto submit the originals.


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L evel premi u m for 3 year sT he premiums are fixed for aperiod of every 3 years. T herewill be no increase in premiumeven if there is a claim in 1 st or2 nd year. In mediclaim, the

premium increases heavilyimmediately after a claim ismade

T he premiums will be reviewed atthe end of 3 years and any

increase will be effected after itis approved by I RDA


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No ho s pitali s ation

Minimum hospitalisation of 24 hours isnot required for 8 4 9 surgeries

24 1 day care surgeries are covered,the highest covered by any Healthplan


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C omprehen s ive Family C overageEach member of the family is covered forthe full benefit with individual sum assured

Kishor Singh has a family of 4 which includeshim, his wife and 2 kids Suppose he wants afamily coverage with Sum Assured of Rs. 5

lakhsUnder mediclaim, all 4 members puttogether are covered for only Rs.5,00,000

In our Silver plan, each member willhave a coverage of Rs. 4 ,90,000 p.a.T he combined family coverage will beRs. 19,60,000


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No claim bon us

In case of any claim free year, the benefits (DHCB + ICUB + SCB)

will be increased by 10% for the next yearT his will also increase the annual and lifetime limit in the sameproportion

T he maximum increase is capped at 50% for each of the abovementioned benefits

In cases where multiple insured are present under one policy, NoClaim Bonus will be credited on individual basis.


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An sw er thi s!

T he Sharmas are a family of 4 Mr. Sharma, Mrs. Sharma andtheir 2 children. T hey all are covered under the Silver Plan.

T here is no claim in the 1 st policy year.

As a result, the sum assured for the 2 nd policy year willincrease. What will it be for each of the family member?

T he sum assured will increase by 10% for each family member:Mr. Sharma Rs. 2 , 2 0,000

Mrs. Sharma R

s.2

,2

0,000Child 1 Rs. 2 , 2 0,000Child 2 Rs. 2 , 2 0,000


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An sw er thi s!

Mr. Singh has bought Diamond Plan covering himself, his wifeand their 2 children.

During the 1 st policy year, Mr. Singh and his elder children hada claim.

What will be the sum assured for each of the family member in

the 2 nd policy year?

T he sum assured will be as follows:Mr. Singh Rs. 4 ,00,000

Mrs. Sharma R

s.4

,4

0,000Child 1 Rs. 4 ,00,000Child 2 Rs. 4 , 4 0,000


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C as hle ss facility Cashless facility is available in the network hospitals. T here aremore than 3000 key hospitals across the country

For non-network hospitals, reimbursements will be done


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C ongenital coverCongenital benefit will cover listed Medically Necessary Surgeriesrequired to correct congenital defects in a child born to a motherwho is continuously covered for a period of 9 months under thepolicy.

T he surgeries covered under this benefit are over and above thedefined list of surgeries under SCB.

Adopted children will be eligible for this benefit if the claim isadmitted within 1 2 months from the date of birth of the adoptedchild

T he benefit paid under this clause will form a part of annual limitand lifetime limit under SCB


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Flexibility Option to upgrade from one planto other at any point of time

Option to add a member anytimeduring the policy term. T herequest for addition should besent along with the additionalpremium

Option to delete a memberanytime during the policy term.Deletion will be effective fromnext premium due date


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Eligibility C riteriaParameter Eligibility C riteria

Minimum age at entry Primary & Secondary Life Assured: 18 years

Child: 90 days

Critical Illness Benefit: 18 years

Maximum age at entry Primary & Secondary Life Assured: 70 years

Child: 17 years

Critical Illness Benefit : 65 years

Maximum age at maturity 85 years

Critical Illness Benefit : 75 years

Premium payment frequency Single, Annual & Semi Annual

Policy term Regular Premium: 15 years

Single Premium: 3 years


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ho can be covered ?

Plan I

You (Proposer & /or Insured)

Spouse (Insured)Upto 3 dependentchildren (Insured)

Primary life insured is the oldest life insured

Secondary life insured is the spouse of the primary life insured


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An sw er thi s!

Mr. Verma is 38 years old and Mrs. Verma is 4 0 years old. T heyhave 2 children aged 15 years and 1 2 years respectively.

Who will be the primary and secondary life insured in thefollowing scenarios?

Primary life insured: Mrs. VermaSecondary life insured: Mr. Verma

Scenario 2 : Mr. Verma is the proposer but not covered under the plan. Mrs. Verma andboth children are covered under the Diamond Plan.

Scenario 1: T hey all are covered under the Silver Plan.

Primary life insured: Mrs. VermaSecondary life insured: None


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Premi u m calc u lationPremium rates will be same for male & female

Premium for family floater will be calculated based on the ageband of the eldest member

Premium for child will be same till the child attains 18 years ofage. Post which the premium for child will be based on individualage band


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Premi u m

AgeGroup

Self Self + Spouse + 1 kidLevel premium Single premium Level premium Single premium

26- 30 Rs. 6,4

71 Rs. 15,4

66 R s. 14

,371 R s. 34

,61531-35 Rs. 6,9 4 1 Rs. 16,61 2 R s.15,31 2 R s. 36,907

36- 40 Rs. 7,636 Rs. 17,576 R s. 16,703 R s 38,8 4 0

Premium for Gold Plan for a total coverage of Rs.735,000

20% Less

20% Less


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Other Fact s


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aiting periodInitial Waiting Period - 90 days from the date of commencement ofcoverage (individual basis)

Specific Waiting Period - 2 years from the date of commencement ofcoverage (individual basis) and applicable to some surgeries

Waiting period will be waived in case of an accident


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Pre-exi s ting C onditionAn illness or bodily injury which has been existing prior to the receipt ofproposal for this policy or prior to the date of reinstatement of this policy:

T he life insured had signs or symptoms which would have caused any ordinaryprudent person to seek treatment, diagnosis or care, or

medical advice or treatment was recommended by or received from aphysician, or

T he life insured had undergone medical tests or investigations.

T hese conditions will be covered under the plan, subject to completedisclosure of the same at the time of proposal and acceptance byunderwriting


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I mportant point s Free look Period 15 days from receipt of policy documents

Grace Period ( Regular Premium) 30 days from the due date ofpremium payment

T he insurance coverage continues during the grace period. In case of aclaim during the grace period, premium due will be debited from thebenefits payable.

Lapsation

No benefit is payable for any ailment diagnosed and/or treated andany hospitalisation undertaken or Surgery carried out during theperiod when the policy has lapsed even though the policy may besubsequently reinstated


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Rein s tatementReinstatement is not possible after 1 year.

Reinstatement would only be done by the Company on receipt of awritten request from the customer accompanied with theoutstanding premium and other documents as detailed below:

From 31st to 90th day: Declaration of good health + Initial WaitingPeriod + Remaining part of Specific Waiting Period

From 90 th day to 1 year: Declaration of good health + InitialWaiting Period + Complete Specific Waiting Period


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Under w ritingMedical underwriting grid:

If the Proposer is not part of the policy as an Insured, housewives with noincome / widow / major students Only Silver & Gold plans are accepted

A ge Silver Gold Diamond / Platinum

1 8 35 No medical No medical No medical

36 45 No medical No medical No medical

46 50 No medical No medical ME R + ECG + ARL I13

51 60 MER + ECG + FBS + R UA +Lipid Profile

MER + ECG + ARL I13 MER + ECG + ARL I13 + CBC +HBA1C

> 60 MER + ECG + ARL I13 MER + ECG + ARL I13 + CBC+ HBA1C

MER + T MT + ARL I13 + CBC +HBA1C


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Excl us ion sAny claim occurring as a result of Pre-existing conditions or their resultantcomplications unless stated in the proposal form and specifically accepted by thecompany and endorsed thereon.

AIDS, HIV related complications or any Sexually T ransmitted Diseases

Attempted suicide or self inflicted injury, irrespective of the mental condition

Hazardous sports or activities included but not limited to bungee jumping,mountaineering etc

Any flying activity other than as a bonafide passenger

Under the influence of alcohol, drugs or any substance not prescribed by aRegistered Medical Practitioner

War, riots, civil commotion, strikes, civil war or service in the military orparamilitary forces of a country at war

Criminal, unlawful or illegal activity participation


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Excl us ion sExposure to radioactive or nuclear fuel

Diagnosis or treatment taken outside India

Psychiatric or mental illness

Circumcision, any Cosmetic procedures or Plastic Surgery

Pregnancy, childbirth or their complications, Abortion, Medical T ermination ofPregnancy, Infertility or sex change operation

Organ donation (donor costs)

Rehabilitation or convalescent care or Length beyond customary length of stay

Non-Allopathic treatment

Purely investigative procedure not resulting in any treatment or unreasonablefailure to seek medical advice

Congenital conditions, genetic disorders or birth defects unless specificallycovered.


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Annex u re 1List of covered surgeries

List of surgeries covered under C ongenital Benefit

Microsoft Excel

Worksheet

2010 File


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T ermination of the policy T he policy terminates under the following circumstances:

T ermination age of 85 years for primary and secondary life insured.

When the Primary policy holder attains 85 years, secondary life insuredcan continue as the primary policy holder.

When secondary life insured attains 85 years of age then the whole policy

will terminate.Death of primary life insured.

Option to continue with secondary life insured as the primary life insuredwill be available.

Date we receive your application for Surrender of the Policy

T he Date of Maturity of the PolicyOn discontinuance of premium.

Not receiving the application for guaranteed renewability within 30 days afterthe end of policy term.


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T hank Yo u

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