individual floater health suraksha ppt-agency 061108

7/31/2019 Individual Floater Health Suraksha Ppt-Agency 061108

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HEALTH SURAKSHA

Health Insurance Plan


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Health Suraksha

Financial Assistance for you and your family against Hospitalisation

Expensesincurred towards disease / illness / injury in India alongwith other additional benefits.


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Basic Features

Value Added Features

Policy Features

Exclusions

Plan Details

Our Advantage

Health Suraksha


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Features

Hospitalisation Expenses

Daycare Treatment

Pre and Post Hospitalisation

Coverage of Pre-Existing Diseases


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(A) Hospitalisation

Policy covers hospitalisation expenses incurred as an in-patient in a Hospital which will include

Room, Boarding and Operation Theatre charges

Fees of Surgeon, Anesthetist, Nurses, Specialists

The cost of diagnostic tests, medicines, blood, oxygen, appliances like pacemaker,

prosthesis/internal implants and any medical expenses incurred which is integral part

of the operation

Hospitalisation for a minimum period of 24 hours is a must except the day care proceduresdefined under the policy.


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(B) Day Care Treatment

Hospitalisation less than 24 hrs

Due to advancement of technology, hospitalisation expenses for certain treatments / diseases like the

following are also covered, even though the hospitalisation is for less than 24 hours

Cardiac Catheterization

Dilation & Curettage

Eye Surgery

Hernia Repair Surgery

Hydrocele Surgery

Lithotripsy (Kidney stone removal)

Radiotherapy Tonsillectomy

Cataract

Chemotherapy

Coronary Angiography

Coronary Angioplasty

Dialysis

For more Day Care Procedures (Total 100 defined), please refer to policy wordings


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(C) Pre and Post Hospitalisation

Policy also covers relevant medical expenses incurred during a specified period, before & after

hospitalization (for which a claim is payable)

Policy Cover Pre-Hospitalisation upto 60 days.

Policy Cover Post-Hospitalisation upto 90 days.

For Limits, please check the Plan Slide


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Definition:

Means any condition, ailment or injury or related condition(s) for which You had signs or

symptoms, and / or were diagnosed and / or received medical advice/ treatment, within 48

months prior to inception of your first policy with Us

Hospitalisation expenses incurred on treatment towards Pre-existing diseases / condition can be

covered:

After completition of 4 years of Consecutive years of policy with FG.

(D) Coverage of Pre-Existing Diseases


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2. Additional Benefits

Additional benefits are payable up to the limits specified

Local Road Ambulance Services Free Medical Health Check up

Patient Care

Hospital Cash

Expenses on accompanying person at the Hospital

Accidental Hospitalisation.

These features become applicable once a valid claim is admitted under the

basic hospitalisation expenses cover of the Policy

.


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(A) Local Road Ambulance Services

Reimbursement of Expenses incurred for necessary transportation of the insured to the Hospital in

an ambulance for hospital admission and requiring immediate treatment.

Benefit under this extension is limited to 1% of the Sum Insured per policy period

subject to maximum of INR 1500/-


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(B) Cost of Health Check up

This benefit provides for reimbursement of cost / charges incurred for medical check up.

Applicable once at the end of a block of4 claim free years.

Reimbursement is as follows:

- Individual Plan: 1% of the sum Insured subject to

maximum of INR 2,500/-

- Family Floater Plan: For 2 People : 1% of the sum

insured subject to maximum of INR 4,000/-


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(C) Patient Care Allowance

Payment of Nursing Allowance for expenses towards employment of registered nurse at the

residence of Insured such services are:

Confirmed as being necessary by the treating Physician

Relate directly to a disease / illness / injury for which the Insured has been hospitalised.

This is applicable for people above 60 years advised nursing at Home after discharged from

hospital.

Allowance is payable for 10 days for any single Hospitalization @ Rs 350/- per day or actuals

whichever is lower. Maximum Day allowance is 30 days during the policy period.


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(D) Hospital Cash Allowance

The Extension is only applicable for Platinum Plan Holder.

The allowance of Rs.500/- per day is allowed for each completed day of Hospitalization

subject to Maximum 60 days during a policy period.

It is irrespective of the number of occurrences

If case two people of the same floater are hospitalized, concurrently, each one of them will be

eligible for hospital daily allowance separately subject to max allowable policy limit.


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(E) Expenses on Accompanying Person

For Hospitalisation of Child less than 10 Years.

Company will pay additional Rs.500/- for each completed day of Hospitalisation subject to

maximum of 30 days during the Policy period

Accompanying person means and includes mother, father, grandmother, grandfather or any

immediate family member.


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(F) Accidental Hospitalization

Increase Limit of Sum Insured available if Hospitalization is due to an accident.

Enhancement of Limits by 25% of Available Sum Insured at the Time of Hospitalization due

to an accident subject to 1 Lakh.


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3. Policy Features

Income Tax Benefit

Individual Plan & Family Floater Plan

Sum Insured

Pre-insurance Health Check up

Option in Policy Duration

Renewal Discount Cashless Facility (Through Third Party Administrators - TPA)

Age Slabs


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(A) Income Tax Benefit

Premium paid for Health Suraksha Policy is eligible for tax deduction under section 80 D of

the Income Tax Act, subject to the condition that the premium amount is paid by any

mode, other than cash

Rs. 15,000/- for self, spouse & Dependent Children.

Rs.15,000/- towards the Health premium for parents.

Rs. 20,000/- if the policy includes senior citizens whose ages is above 65 yrs


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Options Available

Policy can be Opted for Individual Plan & Family Floater Plan

Individual PlanHealth Suraksha (Individual):

Each member has a liberty to chose their own limits and has advantage to utilize it to 100% during the policyperiod.

Has an option to start with a sum insured as low as 100000 /- to Rs. 10 Lakh Subject to Medical approval based

on age and Sum Insured. Sum insured of 50000 can be taken for children only

Parents can be also covered in same plan upto the age of 70 years subject to medical and maximum Sum Insured

of 5 Lakh.

10% Family Discount is applicable in the policy if the insureds are more than one.

Renewal Discount & Cumulative Bonus:

Would be applicable to the members in the policy who have a claims free year of policy for first 5 years. Each

claim free year would have an entitlement of 5% discount on the renewal premium.

From 6th Year, each member would get entitled of Cumulative Bonus of 10% on the basic sum insured upto

maximum of 50% of the sum insured for every claim free year.

Claims Experience Loading

At renewal claims experience loading is charged only on the individual who has made the claim and not on other

members covered under the policy.


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Structuring of Plans based on Geographical classification. Geographical Classification is based on differential Medical Treatment cost in various city.

Why a person living in Bhopal should pay premium equivalent to Delhi/Mumbai, where the

cost of treatment is higher as compared to Bhopal?

Geographical Classification.

Zone A (Mumbai ,Thane and Panvel & Delhi & NCR)

Zone B (Chennai, Kolkata, Ahmedabad, Hyderabad & Bangalore)

Zone C ( All other cities in the country except defined in Zone A & B)

Zone C will have lower premium than Zone B and Zone B would have lower premium than

Zone A for similar benefits.

Plan Available under Health Suraksha (Individual)

i


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Plan Details

Basic Plan: Available for Zone C.

Silver Plan: Available for Zone B.

Gold Plan: Available for Zone A

Platinum Plan: Across India.

What if I opt for Basic Plan (Applicable for Zone C) and take treatment in Zone A.

I have paid Lower premium for Zone C and I decide to take a treatment at high MedicalTreatment Zone A. Company would deduct the %tage from the approved claim amount.

The Next Slide will reflect these deductions in claim amount when there is a difference in

Plan opted and Zone of Treatment.

D d i i Cl i


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(When Plan opted and Treatment Zones are different)

Benefit Plan Zone A Zone B Zone C

Platinum Plan 100%* 100%* 100%*

Gold Plan 100%* 100%* 100%*

Silver Plan 80%* 100%* 100%*

Basic Plan 70%* 80%* 100%*

*The percentage of claim amount shown in the above table is with respect to the eligible claim

amount.

Eg. If a person opts for Platinum or Gold plan, treatment taken irrespective of location (Zone),

100% of Approved claim amount is paid

If a person opts for Silver and takes treatment in Zone A geography is paid only 80% of the

approved claim amount.

If Person opts for Basic and takes treatment in Zone A or Zone B, is paid only 70% of the

approved claim amount.

Deduction in Claims

B fi d i Pl


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Benefit under various PlansS

r#

Scope Payment

BASIC,SILVER & GOLD PLATINUM

1

.

a

Room, Board & Nursing Expenses & Service

Charges Etc

Upto 1% of the SI per day As per Actuals

1

.b

If admitted into Intensive Care Unit Upto 2% of the SI per day As per Actuals

1

.

c

All admissible claims under 1.(a) & 1.(b) during the

policy period

Upto 35% of the Sum Insured per claim As per Actuals

2. Surgeon, Anaesthetist,Consultants, Specialists

Fees


3 Anaesthesia, Blood, Oxygen, OT Charges, Surgical

Appliances


4. Pre-hospitalisation expenses- 60 days Upto 8% of the eligible per hospitalisation expenses. Upto 8% of the eligible per hospitalisation expenses.

5. Post hospitalisation expenses-90 days Upto 10% of the eligible per hospitalisation expenses. Upto 10% of the eligible per hospitalisation expenses.

6. Day Care Expenses Around 100 day care procedures. Around 100 day care procedures.

7. Ambulance charges Upto 1% of SI per policy period up to a max of Rs. 1500 Upto 1% of SI per policy period up to a max of Rs. 1500

8. Free medical check-up For every 4 claim free years- free medical check-up - 1% of

SI up to a max of Rs. 2500, For FF(2-people) - 1% of

SI up to a max of Rs. 4000.

For every 4 claim free years- free medical check-up - 1% of

SI up to a max of Rs. 2500, For FF(2-people) - 1%

of SI up to a max of Rs. 4000.

9. Patient Care Above 60 years-attendant nursing charges after discharge

from the hospital @ Rs 350/- per day or actualswhichever is lower up to a max 10 days -subject to

max of 30 days during the policy period.

Above 60 years-attendant nursing charges after discharge

from the hospital @ Rs 350/- per day or actualswhichever is lower up to a max 10 days -subject to

max of 30 days during the policy period.

1

0

Accidental Hospitalisation Limits under the policy shall increase by 25% of the balance

sum insured available subject to max of Rs.1 Lacs

Limits under the policy shall increase by 25% of the

balance sum insured available subject to max of

Rs.1 Lacs

1

1Hospital Cash NA Rs 500/- for each completed day of hospitalisation subject

to max of 60 days.

1

2

Accompanying Person Rs 500/- for each completed day of hospitalisation in case of

a child up to age of 10 years subject to max of 30

days. Accompanying person means and includes

mother, father, grand father, grand mother, anyimmediate family member.

Rs 500/- for each completed day of hospitalisation in case

of a child up to age of 10 years subject to max of

30 days. Accompanying person means and

includes mother, father, grand father, grand mother,any immediate family member.

Eli ibilit


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Age Eligibility

Age from 5 Years to 70 Years.

Children above 90 days of age can be covered under the policy, if the parents are also covered

at the same time with Future Generali.

Sum Insured Eligibility

Sum Inured under Gold, Silver & Basic plan: Rs.1,00,000/- To Rs. 5,00,000/-

Sum Insured under Platinum Plan: Rs. 6,00,000/- To Rs. 10,00,000/-

Eligibility

U d iti id li


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Acceptance Limit

Age at entry is restricted to 70 years

Family floater policy the eldest age will be considered for premium calculation.

Family floater policy age entry (age for the eldest family member) is restricted to 45 years.

Children above age of 90 days eligible if the parents are concurrently insured with Future

Generali

Minimum SI limit for Individual cover to be 100,000.SI of 50000 can be availed by children

Underwriting guidelines

ROLL OVER CASES


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For person who already have an ongoing policy with the any Insurance Company

Up to 45years -no claim in the previous policy year accept and allow them the NCB

One year policy with any insurer and no claim

Accept with eligible CB and 1st year exclusion is waived.

2 year policy with any insurer and no claim

Accept with eligible CB and 1st year & 2nd year exclusion is waived

3 year policy with any insurer and no claim

Accept with eligible CB and 1st year & 2nd year & 3rd year exclusion is waived

But in any case pre-existing exclusion waiver applicable only after completion of 4 years

with FGI

Above 45 yearsaccept as fresh case with out no claim bonus

ROLL OVER CASES

ROLL OVER CASES


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ROLL OVER CASES

Renewal Discount and Renewal No Claim bonus

The maximum cumulative bonus shall be 50% for those policies where

there is no CB at the time of inception of this policy with FG.For Policies

which have CB at the time of inception of the first policy with FG the

Cumulative bonus shall be restricted to max 70%.

At 6th year in case of no claims the maximum discount availed would be

25% on the renewal premium and 10% cumulative bonus on the expiring

sum insured. The discount of 25% on renewal premium will be applicable

for succeeding year provided there are nil claims. Incase of a claim in thePolicy the Renewal premium discount will be nil and the Cumulative Bonus

will get reduced by 20% for each claim year.

Transfer of CB from previous floater policy to the new floater policy or to an

individual policy is not possible.

MEDICAL UNDERWRITING GUIDELINES


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Taking into account the proposal form and /or the medical reports following restrictions &loadings are applicable.The final acceptance of the proposal will be decided by theunderwriter.

0-35 years 36-45 years

Smoker 10% loading on the standard rates

Hypertension Decline

Ask for FMR, ECG, Lab1 & X-rayChest

Diabetes 20% loading on premium

accept with Diabetes and

related conditions exclusion

Asthma 10% loading on standard

premium accept with

exclusion

Combination of any 2 or

more of (b), (c), (d)

Decline

Any positive history of

any other ailment

For sum insured up to 5 lacs can be decided by the underwriting office

after obtaining medical opinion from the Zonal Underwriter. Above this

please consult HO.

MEDICAL UNDERWRITING GUIDELINES


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Age Of the Person

to be Insured

Sum Insured Medical Examination Tests Required

Under 45 years Up to 5 lacs Not required. Subject to theproposal forms being clean

of any previous

illness/diseases/surgeries.

Under 45 years Over 5 lacs Required FMR, ECG, Lab1, X ray

Chest

Between 46-55years

Up to 3 lacs Not required

Between 46-55

years

More than 3 lacs Required FMR, ECG, Lab1, X ray

Chest, lipid profile

Above 55 years for all sum insured Required FMR, ECG, Lab1, X ray

Chest, Lipid profile

Max Sum Insured available for the Person above 55 years will Be Rs 5 Lacs


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FMR: Full Medical Report by a MD Physician

ECG: Electrocardiogram conducted by the MD

Lipid Profile

Lab 1: includes Fasting Blood Glucose, post prandial blood sugar, Complete Blood Count (inclDiff), Serum Cholesterol, Serum Creatinine, Urinalysis (chemical & microscopic)

X - Ray Chest.

Premium for Health Suraksha (individual)


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Premium for Health Suraksha (individual) Premium is calculated on the basis of

Plan, Sum Insured and Age.

Age to be taken as Completed Age.

Renewal Terms


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Renewal Terms Renewal Premium would be based on Age Band and claim experience.

Loading based on Claim Frequency and Claim amount.

Life Time Indemnity

Insured subscribing to FG Health Suraksha for 1st Time, after 50 Years of age The LifeTime Indemnity Limit is 3 Times of Sum Insured specified in earliest Health SurakshaPlan, if policy is renewed continuously.

Floater Plan


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Health Suraksha Family Floater

Family Floater

Policy can be issued on a Floater basis covering the family members of the Insured

comprising the Insured, spouse and two dependant children (upto the age limit of 21

years).

What is floater, how does it benefit?

All members of the family (Self, Spouse, 2 Kids)

can be covered under one single policy

Single premium payable for the entire family

The amount of Sum Insured floats over the entire family

No need to insure individual members separately

No hassles of tracking renewals for different members

Floater Plan

Family Floater Illustration


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Family: Mr. John Smith, Mrs. Smith & their kid Dooby

Scenario 1:

They take an insurance policy with a SI of Rs.1 Lakh each

Mr. Smith unfortunately needs to undergo Heart Bypass

The total bill amount Rs. 2 lakhs

Insurance company pays only Rs. 1 Lakh as he is covered for only 1 Lakh. He cannot adjust

the rest in the unused coverage amount of his wife and daughter

Mr. Smith needs to bear the reminder of the cost i.e. Rs, 1,00,000/-

Family Floater - Illustration

Family Floater Illustration


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Family: Mr. John Smith, Mrs. Smith & their kid Dooby

Scenario 2:

They take a Health Suraksha Family Floater with a SI of Rs. 3 Lakh for the family

Mr. Simth unfortunately undergoes Heart Bypass

The total bill amount Rs. 2 lakhs

The entire amount is paid by Future Generali

Mr. Smith does not need shell out any money out of his own pocket

Still 1 lakh is Left Unutilized for the policy period for the family.

Family Floater - Illustration

Your Choice!


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Your Choice!

OR

Advantage Floater!


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Chance of all in Mr.Simth family falling ill in one year is low as compared to one member

falling severely ill Theory of probability

Advantage Floater!

Individual Floater

Single cover for each member Common cover for all members

No flexibility to transfer the unutilized limit forother members

The limit can be used by any member of the family& for any number of times

Separate policy (separate document) for family

members

Single document, single premium, single date to

track

Fits all in the Family


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Fits all in the Family

Family covered under floater policy

Choice of cover

Couple

Couple & One kid

Couple & Two kids

Individual & One Kid

Individual & Two Kids

Choice of cover amount

Rs. 2 to 10 Lakh per family depending on the plan selected

Plan Details


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Plan Details

Basic Plan: Available for Zone C.

Silver Plan: Available for Zone B.

Gold Plan: Available for Zone A

Platinum Plan: Across India.

What if I opt for Basic Plan (Applicable for Zone C) and take treatment in Zone A.

I have paid Lower premium for Zone C and I decide to take a treatment at high Medical Treatment

Zone A. Company would deduct the %tage from the approved claim amount.

The Next Slide will reflect these deductions in claim amount when there is a difference in Plan opted

and Zone of Treatment.

The other terms and conditions are same as that of Individual Health Suraksha.

Eligibility


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Age Eligibility

Age from 5 Years to 45 Years.

Children above 90 days of age can be covered under the policy, if the parents are also covered

at the same time with Future Generali.

Sum Insured Eligibility

Sum Inured under Gold, Silver & Basic plan: Rs.2,00,000/- To Rs. 5,00,000/-

Sum Insured under Platinum Plan: Rs. 6,00,000/- To Rs. 10,00,000/-

Eligibility

Exclusions


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Exclusions

Certain diseases like cataract, hernia , tumors shall be covered after a waiting period of 2years.

Certain diseases/surgeries like gallstones, renal stones shall be covered after a waiting periodof 1 year.

Any condition, ailment or injury or related conditions for which you have been diagnosed,

received medical treatment, had signs and / or symptoms, prior to inception of your first

policy, until 48 consecutive months have elapsed, after the date of inception of the first policy

with Future Generali.

Joint replacement surgery shall be covered after a waiting period of 3 years except done due

to an accident.

Any disease contacted during the first 30 days of inception of policy accidents excluded and

roll over cases excluded

Non-allopathic treatment

Pregnancy & childbirth related diseases

Premium chart For Family Floater


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Premium chart For Family Floater


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CLAIMS PROCESS

Types of claims


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Hospitalisation

Claims can be broadly of two types:

Reimbursement claims

Cashless claims Through our TPA Dedicated Health Services Limited

This further can be broken into:

Planned - Where the customer is aware of the hospitalisation atleast 72 hours in advance

Emergency - Where the customer meets with an accident or suffers from bout of illness thatrequires immediate admission to the hospital

Claims are serviced at both network as well as non-network hospitals

Network hospitals Hospitals which are on the tied up list (more than 3000 hospitals covered) -

Where our service provider has a relationship

Non-network hospitals which do not form part of the list

Types of claims

Reimbursement


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Steps to follow during hospitalisation

A) Emergency hospitalisation

Step 1. Take admission into the hospital. Step 2. As soon as possible, inform TPA about the hospitalisation.

Step 3. At the time of discharge, to settle the hospital bills in full and collect all the original bills,documents and reports.

Step 4. Lodge the claim with TPA for processing and reimbursement by duly filling in the claimform & enclosing all original bills/vouchers/receipts

B) Planned hospitalisation

Step 1. Inform TPA about the planned hospitalisation.

Step 2. Get admitted into the hospital as planned.

Step 3. At the time of discharge, to settle the hospital bills in full andcollect all the bills, documents and reports.

Step 4. Lodge the claim with TPA for processing and

reimbursement by duly filling in the claim form & enclosing alloriginal bills/vouchers/receipts

Reimbursement

Reimbursement Claims


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Claim procedure

As soon as hospitalised, to intimate the TPA (Help line/Toll free number mentioned in the

Health Card)

Following information needs to be furnished while intimating a claim:

Contact Numbers

Policy Number (as reflecting on the Health Card)

Name of Insured person who is Sick or Injured

Nature of Sickness/Accident

Date & Time in case of accident, commencement date of symptom of disease in case of

sickness

Location of accident

Reimbursement Claims

Cashless Claims


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Procedure (Approval)

Cashless Service is the service wherein the Insured need not pay any money at the time ofadmission or discharge.

This facility is available only at our Network Hospitals

To avail the CashlessService

Cashless Request Form available in network hospital is to be filled up and sent to TPAfor getting authorisation from TPA. The Hospital will coordinate for this.

This authorisation along with a copy of the Health Card has to be given to the NetworkProvider at the time of admission

Please also keep a copy of any photo ID card, it may be required by the Hospital.

TPA will authorize Cashless Service at the Network Hospitals for all cases which arecovered under the policy.

Cashless Claims

Cashless Claims


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Procedures (Denial)

CashlessService may be denied in following situations:

In case of any doubt in the coverage of treatment of present ailment under the Policy

If the information sent to TPA is insufficient to confirm coverage

The ailment/condition etc. not being covered under the policy

If the request for pre-authorisation is not received by TPA in time

Denial of Cashless Service is not denial of treatment. The Insured can continue with the

treatment, pay for the treatment to the hospital and after discharge send the claim to TPA for

processing.

Cashless Claims

Cashless Claims


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Procedures for emergency hospitalisation

Rush to hospital and get admitted.

Obtain the Pre-Authorisation Form from the hospital (if it network).

Get the same filled in & signed by the attending doctor with required details.

Fax the pre-authorization form along with necessary medical details to TPA at the number

mentioned in health card. The Hospital will coordinate for this.

Cas ess C a s

Cashless Claims


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Procedures for emergency hospitalisation

If pre-authorisation is received from the TPA for CashlessService

At the time of discharge.

Verify the bills and sign on all the bills at the Hospital.

Pay only for those items that are not reimbursable under the Policy (Hospital / TPA will

guide in this).

Leave the original discharge summary & other investigations reports with the hospital.

Retain a Xerox copy for records.

Cashless Claims


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Procedures for Planned hospitalisation

Coordinate with hospital & send in all the details along with the Pre-Authorisation Form at least 2

days prior to the hospitalisation including the plan of treatment, cost estimates etc. to TPA.

If CashlessService is authorised by TPA

At the time of admission, handover in the authorisation letter of TPA for cashless service & a

photocopy of ID card to the hospital.

At the time of discharge

a. Verify the bills and sign on all the bills.

b. Pay only for those items that are not reimbursable under the Policy.

c. Leave the original discharge summary, other reports with the hospital. Retain a Xerox

copy for records.


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Thank you

individual floater health suraksha ppt-agency 061108

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