sales prospectus 2 - · pdf filemax india limited: a reputation for excellence introducing max...

LITERATURESALES

PROSPECTUS

SWASTHYA PRATHAMMICRO INSURANCE PRODUCT

Disclaimer: This is only a summary of the product features and is for reference purpose only. The details of benefits

available shall be as described in the policy document, and will be subject to the policy terms, conditions and

exclusions. Please call our customer service if you require any further information or clarification.

Statutory Warning: Prohibition of rebates (under section 41 of Insurance Act 1938); no person shall allow or offer

to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance

in respect of any kind of risk relating to life or property, in India, any rebate of the whole or part of the commission

payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or

continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published

prospectus or the tables of the insurer. Any person making default in complying with the provision of this section

shall be punished with fine, which may extend to five hundred rupees.

What to do next

Phone: 1800 3010 3333 (Toll Free) or 011-3300 3333

Web: www.maxbupa.com

If you wish to know more about Max Bupa’s Swasthya Pratham Micro

Insurance Product and/or would like a personal quote, speak to our specially

trained sales team or your local advisor. They’ll take time to fully understand

your requirements and help you to select the right plan for you.

&LITERATURE&LITERATURESALES&SALES

Max Bupa Health Insurance Company LimitedCorporate Office : 2nd Floor, Salcon Ras Vilas, D-1, District Centre, Saket, New Delhi 110017

Registered Office : Max House, 1 Dr. Jha Marg, Okhla, New Delhi 110020www.maxbupa.com

‘Max’, Max Logo are registered trademarks of Max India Limited“Bupa” and the HEARTBEAT logo are the registered service marks of the The British United Provident Association Limited

All these marks are being used under license by Max Bupa Health Insurance Company Limited.

Insurance is the subject matter of solicitation

Max India Limited: A Reputation for Excellence

Introducing Max Bupa Health Insurance Company Limited, a joint venture between Max India Limited and Bupa

Finance Plc., U.K. We believe in nurturing long-term relationship with our customers by providing the highest levels of

quality in service.

OUR PARENT COMPANIES

Max Group brings expertise in insurance and

healthcare with a strong presence in Life Insurance

(through Max New York Life Insurance Company

Limited), Healthcare (through Max Healthcare Institute

Ltd.) and Clinical Research (through Max Neeman

Medical International Limited).

A Rs.7,700 crore group, it has over 700 offices across

more than 500 locations in India as well as 4 million

customers, and over 1 lac people, all focused on

delivering customer satisfaction (Source-Max India Ltd.

Annual Report 2009-10).

Bupa: 60 Years of Care

Established in 1947 as the British United Provident

Association, Bupa today has over 10 million customers

in over 190 countries (Source-www.maxbupa.com).

Bupa Group brings in a wealth of experience in serving

customers directly in health insurance across the

world. In addition to quality health insurance, Bupa

runs care homes for elderly people and the young

disabled, health assessments & health coaching and

workplace health programmes for customers.

Recognition and Awards

SWASTHYA PRATHAM MICRO INSURANCE PRODUCT

Start a healthy relationshipSWASTHYA PRATHAM MICRO INSURANCE PRODUCTYour search for high quality health insurance stops here.

Swasthya Pratham Micro Insurance Product is a group

health insurance cover which is simple to buy and easy

to understand. In addition to providing a core health

insurance cover to suit your needs, this plan helps you

proactively take care of the health of your group and

their dependants. We are here to build a long term

healthy relationship with your group and its members.

We believe that a healthy relationship is built by

understanding your needs, by coming closer to you,

through a continuous dialogue with you on what

matters the most to you.

Policy Design

• Swasthya Pratham Micro Insurance Product can

cover the members of your group and her/his

family under the same limit. The cover includes the

member, members spouse and any three

dependent children (under 18 years). Family under

the Swasthya Pratham Micro Insurance Product

includes the following:

1. Spouse (Legally married)

2. Son

3. Daughter

• This policy covers Main member in the age 18-65

Years and dependents in the age group 3 months

to 65 years.

• The tenure of the policy is one year.

Sum Insured

• The sum insured options- range from Rs. 5,000 to

Rs. 30,000 for Individuals and Rs 10,000 to Rs

30,000 for family floater policies, depending on

the plan you choose. The details of the plans are

available in the product benefits table.

Product Features and Benefits–Key HighlightsThe policy covers reasonable and customary expenses

incurred towards medical treatment taken during the

Policy Period for an Illness or an Accident. We cover the

following expenses:

1. In-patient Treatment: Medical Expenses for:

(i) Doctors’ fees

(ii) Diagnostics Tests

(iii) Medicines, drugs and consumables

(iv) Intravenous fluids, blood transfusion, injection

administration charges

(v) Operation theatre charges

(vi) The cost of prosthetics and other devices or

equipment if implanted internally during a

Surgical Operation.

(vii) Intensive Care Unit charges

(viii) Room (General Ward), boarding expenses

(ix) Nursing expenses

2. Hospital Accommodation: Reasonable and

Customary charges for Hospital accommodation.

3. Pre & Post hospitalization Medical Expenses: Medical Expenses incurred due to Illness up to 7

days period immediately before an Insured

Person’s admission to a Hospital and 15 days

immediately after an Insured Person’s discharge

from a Hospital. These expenses are restricted to Rs

150 per hospitalization or 1.5% of Sum Insured

(whichever is higher).

4. Day Care Procedures: Medical Expenses for day

care procedures where such procedures are

undertaken by an Insured Person as an inpatient in

Max India Limited:

• Max New York Life was declared a “Superbrand” by

Superbrands India in the 3rd edition of Consumer

Superbrands 2008’

• CII-Exim Bank Award for Business Excellence awarded to Max New York Life in 2008

• CIO 100 Award for technology implementation

• The Health Insurance Company of the Year Award -

awarded at the U.K. Health Insurance Awards 2009

• Best International Private Medical Insurance provider

2008 - awarded at the U.K. Health Insurance Awards

• Best Medical Insurer Company (2008, Bupa Arabia)

- awarded at the Jeddah Chamber of Commerce and

Industry Health Committee Awards

• Best Healthcare Provider of the Year - awarded at the

U.K. Corporate Adviser Awards 2009

• Best Individual Private Medical Insurance Provider

- awarded at the U.K. Money Marketing Awards 2009 Sourse: www.bupa.com

Max India Limited: A Reputation for Excellence

Introducing Max Bupa Health Insurance Company Limited, a joint venture between Max India Limited and Bupa

Finance Plc., U.K. We believe in nurturing long-term relationship with our customers by providing the highest levels of

quality in service.

OUR PARENT COMPANIES

Max Group brings expertise in insurance and

healthcare with a strong presence in Life Insurance

(through Max New York Life Insurance Company

Limited), Healthcare (through Max Healthcare Institute

Ltd.) and Clinical Research (through Max Neeman

Medical International Limited).

A Rs.7,700 crore group, it has over 700 offices across

more than 500 locations in India as well as 4 million

customers, and over 1 lac people, all focused on

delivering customer satisfaction (Source-Max India Ltd.

Annual Report 2009-10).

Bupa: 60 Years of Care

Established in 1947 as the British United Provident

Association, Bupa today has over 10 million customers

in over 190 countries (Source-www.maxbupa.com).

Bupa Group brings in a wealth of experience in serving

customers directly in health insurance across the

world. In addition to quality health insurance, Bupa

runs care homes for elderly people and the young

disabled, health assessments & health coaching and

workplace health programmes for customers.

Recognition and Awards

SWASTHYA PRATHAM MICRO INSURANCE PRODUCT

Start a healthy relationshipSWASTHYA PRATHAM MICRO INSURANCE PRODUCTYour search for high quality health insurance stops here.

Swasthya Pratham Micro Insurance Product is a group

health insurance cover which is simple to buy and easy

to understand. In addition to providing a core health

insurance cover to suit your needs, this plan helps you

proactively take care of the health of your group and

their dependants. We are here to build a long term

healthy relationship with your group and its members.

We believe that a healthy relationship is built by

understanding your needs, by coming closer to you,

through a continuous dialogue with you on what

matters the most to you.

Policy Design

• Swasthya Pratham Micro Insurance Product can

cover the members of your group and her/his

family under the same limit. The cover includes the

member, members spouse and any three

dependent children (under 18 years). Family under

the Swasthya Pratham Micro Insurance Product

includes the following:

1. Spouse (Legally married)

2. Son

3. Daughter

• This policy covers Main member in the age 18-65

Years and dependents in the age group 3 months

to 65 years.

• The tenure of the policy is one year.

Sum Insured

• The sum insured options- range from Rs. 5,000 to

Rs. 30,000 for Individuals and Rs 10,000 to Rs

30,000 for family floater policies, depending on

the plan you choose. The details of the plans are

available in the product benefits table.

Product Features and Benefits–Key HighlightsThe policy covers reasonable and customary expenses

incurred towards medical treatment taken during the

Policy Period for an Illness or an Accident. We cover the

following expenses:

1. In-patient Treatment: Medical Expenses for:

(i) Doctors’ fees

(ii) Diagnostics Tests

(iii) Medicines, drugs and consumables

(iv) Intravenous fluids, blood transfusion, injection

administration charges

(v) Operation theatre charges

(vi) The cost of prosthetics and other devices or

equipment if implanted internally during a

Surgical Operation.

(vii) Intensive Care Unit charges

(viii) Room (General Ward), boarding expenses

(ix) Nursing expenses

2. Hospital Accommodation: Reasonable and

Customary charges for Hospital accommodation.

3. Pre & Post hospitalization Medical Expenses: Medical Expenses incurred due to Illness up to 7

days period immediately before an Insured

Person’s admission to a Hospital and 15 days

immediately after an Insured Person’s discharge

from a Hospital. These expenses are restricted to Rs

150 per hospitalization or 1.5% of Sum Insured

(whichever is higher).

4. Day Care Procedures: Medical Expenses for day

care procedures where such procedures are

undertaken by an Insured Person as an inpatient in

Max India Limited:

• Max New York Life was declared a “Superbrand” by

Superbrands India in the 3rd edition of Consumer

Superbrands 2008’

• CII-Exim Bank Award for Business Excellence awarded to Max New York Life in 2008

• CIO 100 Award for technology implementation

• The Health Insurance Company of the Year Award -

awarded at the U.K. Health Insurance Awards 2009

• Best International Private Medical Insurance provider

2008 - awarded at the U.K. Health Insurance Awards

• Best Medical Insurer Company (2008, Bupa Arabia)

- awarded at the Jeddah Chamber of Commerce and

Industry Health Committee Awards

• Best Healthcare Provider of the Year - awarded at the

U.K. Corporate Adviser Awards 2009

• Best Individual Private Medical Insurance Provider

- awarded at the U.K. Money Marketing Awards 2009 Sourse: www.bupa.com

a Hospital for a continuous period of less than 24

hours. Any procedure undertaken at the

out-patient department of a Hospital will not be

covered.

List of Day Care Procedures covered under the

Policy is as follows:i. Haemo-Dialysisii. Parenateral Chemotherapyiii. Radiotherapyiv. Eye Surgeryv. Lithotripsy ( kidney stone removal)vi. Tonsillectomyvii. D&Cviii. Surgery of Hydroceleix. Surgery of Prostrate

x. Gastrointestinal Surgery xi. Genital Surgery xii. Surgery of Nose xii. Surgery of Throat xiv. Surgery of Ear xv. Surgery of Urinary System xvi. Treatment of fractures / dislocation (excluding

hair line fracture), Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalization.

xvii. Laparoscopic therapeutic surgeries that can

be done in a day care

Additional Benefits that can be purchased for extra premium

a) Maternity & New Born Benefits:

i) Maternity Benefits: This benefit is available

for the Primary Insured or his spouse provided

that the Primary Insured and his/her spouse,

are both covered under the same Policy.

However in the case of a widow covered

under the Policy, the benefit under this clause

can be availed in respect of the pregnancy

conceived by her when she and her husband

were both covered under the immediately

preceding policy with Us, We will also cover

medically necessary termination of pregnancy.

However, we do not cover expenses in respect

of harvesting and storage of stem cells.

a. We will pay Rs. 3000 for Normal Delivery and

Rs. 5000 for Cesarean

b. No home birth allowed

c. Cover 2 deliveries, in the entire policy lifetime

per couple

d. Pre and post hospitalization covered with

maximum 7 days of pre and 15 days of post

hospitalization. This will be part of Maternity

e. Expense related to Pre Mature Delivery will be

part of overall Maternity Cover

ii) New Born Baby: The new born baby will be

covered as an insured person from day 91

with no extra premium till renewal.

b) Personal Accident: If the Primary Insured or his

spouse (provided that she is an Insured Person)

dies during the Policy Period solely and directly due

to an Accident which occurs during the Policy

Period, then We will pay the Personal Accident Sum

Insured specified in the Schedule. We will not

make any payment under this endorsement if the

death of the Primary Insured or his spouse is due

to or arises from any of the following:

a. Any existing disability

b. Self injury

c. Natural calamities

d. Homicide

e. Suicide

f. Influence of liquor or drugs

g. Result of racing, big games, hunting,

mountaineering and adventure sports

h. Insanity

i. Any war or act of terrorism

j. Result of being part of nuclear group

Cover is available only to Primary Insured and his/her

Spouse. Cover is available for age 18 years to 65

years.

Out Patient Benefits

We will cover expenses upto Rs. 500 (per cover under

each Certificate of Insurance) related to following

diagnostic tests, if prescribed by a Doctor and are

conducted only in the Network Hospitals:

a. ECG;

b. Chest X-ray;

c. Test for Hemoglobin;

d. Test for Blood Sugar;

e. Test for Urea;

f. Test for Creatinine

Claims made in respect of this benefit will not be

subject to the Sum Insured.

Meal Allowance

We will pay meal allowance per day if the Insured

Person is admitted in a Network Hospital for each

continuous and completed period of 24 hours of the

Hospitalization, after first 48 hours of Hospitalization,

provided that We have accepted an In-patient

Hospitalization claim . We will pay Rs 30 per day

maximum up to Rs 210 per cover under each

Certificate of Insurance.

Wage Loss

We will pay for the loss of wage per day if the Primary

Insured is admitted in a Network Hospital for each

Hospitalization, after first 48 hours of Hospitalization

Hospitalization . We will pay Rs 100 per day of

hospitalization maximum of Rs 700 per cover under

each Certificate of Insurance.

Transport Allowance (In case of Inpatient Treatment

for emergency cases only): Max upto Rs 1000 per

cover under each Certificate of Insurance and Max

Rs 600 per hospitilsation. Claims made in respect of

this benefit will not be subject to the Sum Insured.

By Stander Allowance (Subject to 48 hours

hospitilisation): Rs 50 per day max of Rs 350 (as

applicable under the policy) under each Certificate of

Insurance. By stander here means, means A person

who accompanies the insured during his/her

hospitalization throughout the entire tenure of

hospitalization.

Waivers available for Purchase:

• 30 day no claim/waiting period from policy

inception

• 24 month waiting period from for Specific

Exclusions

• Pre-existing disease exclusions waivers

Waiting Periods and Exclusions

Claims for the following are not covered:

• Pre-Existing Conditions: Benefits will not be

available for Pre-existing Conditions until 48

months of continuous coverage have elapsed since

the inception of the first Policy with us.

• 30 Days Waiting Period: We will not cover any

treatment taken during the first 30 days since the

commencement of the Policy, unless the treatment

needed is a result of an Accident or Emergency.

This waiting period does not apply for any

subsequent and continuous renewals of Your

Policy.

a Hospital for a continuous period of less than 24

hours. Any procedure undertaken at the

out-patient department of a Hospital will not be

covered.

List of Day Care Procedures covered under the

Policy is as follows:i. Haemo-Dialysisii. Parenateral Chemotherapyiii. Radiotherapyiv. Eye Surgeryv. Lithotripsy ( kidney stone removal)vi. Tonsillectomyvii. D&Cviii. Surgery of Hydroceleix. Surgery of Prostrate

x. Gastrointestinal Surgery xi. Genital Surgery xii. Surgery of Nose xii. Surgery of Throat xiv. Surgery of Ear xv. Surgery of Urinary System xvi. Treatment of fractures / dislocation (excluding

hair line fracture), Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalization.

xvii. Laparoscopic therapeutic surgeries that can

be done in a day care

Additional Benefits that can be purchased for extra premium

a) Maternity & New Born Benefits:

i) Maternity Benefits: This benefit is available

for the Primary Insured or his spouse provided

that the Primary Insured and his/her spouse,

are both covered under the same Policy.

However in the case of a widow covered

under the Policy, the benefit under this clause

can be availed in respect of the pregnancy

conceived by her when she and her husband

were both covered under the immediately

preceding policy with Us, We will also cover

medically necessary termination of pregnancy.

However, we do not cover expenses in respect

of harvesting and storage of stem cells.

a. We will pay Rs. 3000 for Normal Delivery and

Rs. 5000 for Cesarean

b. No home birth allowed

c. Cover 2 deliveries, in the entire policy lifetime

per couple

d. Pre and post hospitalization covered with

maximum 7 days of pre and 15 days of post

hospitalization. This will be part of Maternity

e. Expense related to Pre Mature Delivery will be

part of overall Maternity Cover

ii) New Born Baby: The new born baby will be

covered as an insured person from day 91

with no extra premium till renewal.

b) Personal Accident: If the Primary Insured or his

spouse (provided that she is an Insured Person)

dies during the Policy Period solely and directly due

to an Accident which occurs during the Policy

Period, then We will pay the Personal Accident Sum

Insured specified in the Schedule. We will not

make any payment under this endorsement if the

death of the Primary Insured or his spouse is due

to or arises from any of the following:

a. Any existing disability

b. Self injury

c. Natural calamities

d. Homicide

e. Suicide

f. Influence of liquor or drugs

g. Result of racing, big games, hunting,

mountaineering and adventure sports

h. Insanity

i. Any war or act of terrorism

j. Result of being part of nuclear group

Cover is available only to Primary Insured and his/her

Spouse. Cover is available for age 18 years to 65

years.

Out Patient Benefits

We will cover expenses upto Rs. 500 (per cover under

each Certificate of Insurance) related to following

diagnostic tests, if prescribed by a Doctor and are

conducted only in the Network Hospitals:

a. ECG;

b. Chest X-ray;

c. Test for Hemoglobin;

d. Test for Blood Sugar;

e. Test for Urea;

f. Test for Creatinine

Meal Allowance

We will pay meal allowance per day if the Insured

Person is admitted in a Network Hospital for each

Hospitalization, after first 48 hours of Hospitalization,

Hospitalization claim . We will pay Rs 30 per day

maximum up to Rs 210 per cover under each

Certificate of Insurance.

Wage Loss

We will pay for the loss of wage per day if the Primary

Insured is admitted in a Network Hospital for each

Hospitalization, after first 48 hours of Hospitalization

Hospitalization . We will pay Rs 100 per day of

hospitalization maximum of Rs 700 per cover under

each Certificate of Insurance.

Transport Allowance (In case of Inpatient Treatment

for emergency cases only): Max upto Rs 1000 per

cover under each Certificate of Insurance and Max

Rs 600 per hospitilsation. Claims made in respect of

this benefit will not be subject to the Sum Insured.

By Stander Allowance (Subject to 48 hours

hospitilisation): Rs 50 per day max of Rs 350 (as

applicable under the policy) under each Certificate of

Insurance. By stander here means, means A person

who accompanies the insured during his/her

hospitalization throughout the entire tenure of

hospitalization.

Waivers available for Purchase:

• 30 day no claim/waiting period from policy

inception

• 24 month waiting period from for Specific

Exclusions

• Pre-existing disease exclusions waivers

Waiting Periods and Exclusions

Claims for the following are not covered:

• Pre-Existing Conditions: Benefits will not be

available for Pre-existing Conditions until 48

months of continuous coverage have elapsed since

the inception of the first Policy with us.

• 30 Days Waiting Period: We will not cover any

treatment taken during the first 30 days since the

commencement of the Policy, unless the treatment

needed is a result of an Accident or Emergency.

This waiting period does not apply for any

subsequent and continuous renewals of Your

Policy.

• Mastoidectomy (operation to remove piece of

bone behind the ear)

• Tympanoplasty (Surgery to repair tympanic

membrance aka eardrum)

• Undescended testis

• Surgery of genito urinary tract

• Permanent Exclusions: Addictive conditions and

disorders; Ageing and puberty; Artificial life

maintenance; Circumcision; Conflict and disaster;

Congenital conditions; Convalescence and

rehabilitation; Cosmetic surgery; Dental/oral

treatment; Domicillary Treatment; Drugs and

dressings for outpatient or take-home use;

Eyesight; Experimental treatment; Health hydros,

nature cure, wellness clinics etc.; HIV and AIDS;

Hereditary conditions; Items of personal comfort

and convenience; Non-allopathic treatment;

Neurological and Psychiatric Conditions; Obesity;

Organ Donor; Out Patient Treatment; Reproductive

medicine - Birth control & Assisted reproduction;

Self-inflicted injuries; Sexual problems and gender

issues; Sexually transmitted diseases; Sleep

disorders; Speech disorders; Treatment for

developmental problems; Treatment received

outside India; Unrecognised physician or facility;

Unlawful activity.

For details of permanent exclusions please read Terms

and Condition document or visit:

www.maxbupa.com/exclusions

Cancellation1. Cancellation/Termination :

a. Automatic Cancellation/Termination:

The Policy shall automatically terminate in the case

of death of all the Insured Persons.

b. Cancellation by Us:

We may terminate this Policy/ cover under

Certificate of Insurance by sending 30 days prior

written notice to Your address shown in the

Schedule without refund of premium if in Our

opinion:

i. You or any Insured Person or any person acting on

behalf of either has acted in a dishonest or

fraudulent manner, provided false or incorrect

information, or suppressed any important

information, under or in relation to this Policy/ cover

under Certificate of Insurance; and/or

ii. Continuance of the Policy/ cover under Certificate of

Insurance poses a moral hazard;

1. Cancellation by Policyholder:The Policyholder may terminate this Policy by giving 7 days’ prior written notice to Us. We shall cancel the Policy and refund the premium for the period as mentioned herein below, provided that no claim has been reported under the Policy by or on behalf of any claim, if reported after the termination date of the Policy.

Length of time Reffund of premiumPolicy in forceup to 30 days 75%up to 90 days 50%up to 180 days 25%exceeding 180days 0%

The Policyholder shall be responsible for making refund of premium to the Primary Insured in proportion to premium, if any, paid by them.

Renewal Information1. Renewal Premium: The renewal premium is

payable on or before the due date as shown in the

Schedule. The premium may change on renewal.

2. Waiting Period: The Waiting Periods mentioned in

the policy wording will get reduced by 1 year with

every continuous renewal of your Swasthya Pratham

Micro Insurance Product.

3. Maximum Age: There is no maximum cover ceasing

age in this policy.

Claims Procedure

• Cashless Hospitalization Facility for Network

Hospitals: We will provide cashless hospitalization

facility at our network hospitals. For any treatment

taken at non network hospital the insured will

have to bear 20% co-pay for the claim amount.

We/TPA will pre-authorise all cashless in-patient and

day care procedure, if intimated to us/TPA 72 hours

before hospitalization (within 48 hours after

hospitalization for emergency). Under cashless

Hospitalization, claims are paid directly to the

Network Hospital. For cashless Hospitalization TPA will

make the payment of the amounts assessed to be due

directly to the Network Hospital. The treatment must

take place within 15 days of the pre-authorization

date and pre-authorization is only valid if all the

details of the

authorized treatment, including dates, diagnosis,

treatment, clinical details, Hospital and locations,

match with the details of the actual treatment

received.

• All Other Claims for Reimbursement: We should be

notified in writing with a request to pre-authorise

expenditure to be reimbursed under this Policy at leat

72 hours prior to the planned date of such treatment,

consultation or procedure being taken and We must

have pre-authorised such treatment, consultation,

service or procedure. In an Emergency the Insured

Person should notify Us in writing within 48 hours of

Hospitalization.

• In case of all claims made for treatment at

Out-Of-Network hospittals, the insured will have to

bear 20% co-pay for te amont assessed for the

reimbursement in respect of claim.

• To claim re-imbursements for any Illness or Accident

or medical condition that requires Hospitalization, the

Insured Person should provide us/TPA the documents

listed below, within 15 days of the Insured Person's

discharge from Hospital:

• Specific Waiting Periods: For all Insured Persons,

the conditions listed below will be subject to a

waiting period of 24 months and will be covered in

the third Policy Year as long as the Insured Person

has been insured continuously under the Policy

without any break:

• Gout

• Rheumatism

• Hypertension

• DM

• Varicose veins & Varicose ulcers

• Hemorrhoids (Piles)

• Migraine / Vascular headaches

• Stones in the urinary system

• Stones in billiary system

• Surgery on tonsils / adenoids

• Any type of cysts, nodules, polyps

• Any type of breast lumps

• Treatment of spondylosis/spondylitis - any type

• IVDP & such other degenerative disorders

• Benign Hypertrophic Prostatectomy

• Hysterectomy / Myomectomy done due to Fibroids and/or Mennorhagia

• Heart diseases

• Any type of Carcinoma/sarcoma/blood cancer

• Osteo Arthritis of any joint

• Gastric and duodenal Ulcers

• Thyroidectomy for nodule/multinodular goitre

• Varicocele

• Spermatocele

• Rectal Prolapse

• D&C

• Vitrectomy & retinal detachment surgery for retinopathy

• Amputation due to diabetes

• Fistula in ano

• Fissure in ano

• Her nia

• Hydrocele

• Sinusitis

• Knee / hip joint replacement

• CRF or end stage renal failure

• Cataract

• Mastoidectomy (operation to remove piece of

bone behind the ear)

• Tympanoplasty (Surgery to repair tympanic

membrance aka eardrum)

• Undescended testis

• Surgery of genito urinary tract

• Permanent Exclusions: Addictive conditions and

disorders; Ageing and puberty; Artificial life

maintenance; Circumcision; Conflict and disaster;

Congenital conditions; Convalescence and

rehabilitation; Cosmetic surgery; Dental/oral

treatment; Domicillary Treatment; Drugs and

dressings for outpatient or take-home use;

Eyesight; Experimental treatment; Health hydros,

nature cure, wellness clinics etc.; HIV and AIDS;

Hereditary conditions; Items of personal comfort

and convenience; Non-allopathic treatment;

Neurological and Psychiatric Conditions; Obesity;

Organ Donor; Out Patient Treatment; Reproductive

medicine - Birth control & Assisted reproduction;

Self-inflicted injuries; Sexual problems and gender

issues; Sexually transmitted diseases; Sleep

disorders; Speech disorders; Treatment for

developmental problems; Treatment received

outside India; Unrecognised physician or facility;

Unlawful activity.

For details of permanent exclusions please read Terms

and Condition document or visit:

www.maxbupa.com/exclusions

Cancellation1. Cancellation/Termination :

a. Automatic Cancellation/Termination:

The Policy shall automatically terminate in the case

of death of all the Insured Persons.

b. Cancellation by Us:

We may terminate this Policy/ cover under

Certificate of Insurance by sending 30 days prior

written notice to Your address shown in the

Schedule without refund of premium if in Our

opinion:

i. You or any Insured Person or any person acting on

behalf of either has acted in a dishonest or

fraudulent manner, provided false or incorrect

information, or suppressed any important

information, under or in relation to this Policy/ cover

under Certificate of Insurance; and/or

ii. Continuance of the Policy/ cover under Certificate of

Insurance poses a moral hazard;

1. Cancellation by Policyholder:The Policyholder may terminate this Policy by giving 7 days’ prior written notice to Us. We shall cancel the Policy and refund the premium for the period as mentioned herein below, provided that no claim has been reported under the Policy by or on behalf of any claim, if reported after the termination date of the Policy.

Length of time Reffund of premiumPolicy in forceup to 30 days 75%up to 90 days 50%up to 180 days 25%exceeding 180days 0%

The Policyholder shall be responsible for making refund of premium to the Primary Insured in proportion to premium, if any, paid by them.

Renewal Information1. Renewal Premium: The renewal premium is

payable on or before the due date as shown in the

Schedule. The premium may change on renewal.

2. Waiting Period: The Waiting Periods mentioned in

the policy wording will get reduced by 1 year with

every continuous renewal of your Swasthya Pratham

Micro Insurance Product.

3. Maximum Age: There is no maximum cover ceasing

age in this policy.

Claims Procedure

• Cashless Hospitalization Facility for Network

Hospitals: We will provide cashless hospitalization

facility at our network hospitals. For any treatment

taken at non network hospital the insured will

have to bear 20% co-pay for the claim amount.

We/TPA will pre-authorise all cashless in-patient and

day care procedure, if intimated to us/TPA 72 hours

before hospitalization (within 48 hours after

hospitalization for emergency). Under cashless

Hospitalization, claims are paid directly to the

Network Hospital. For cashless Hospitalization TPA will

make the payment of the amounts assessed to be due

directly to the Network Hospital. The treatment must

take place within 15 days of the pre-authorization

date and pre-authorization is only valid if all the

details of the

authorized treatment, including dates, diagnosis,

treatment, clinical details, Hospital and locations,

match with the details of the actual treatment

received.

• All Other Claims for Reimbursement: We should be

notified in writing with a request to pre-authorise

expenditure to be reimbursed under this Policy at leat

72 hours prior to the planned date of such treatment,

consultation or procedure being taken and We must

have pre-authorised such treatment, consultation,

service or procedure. In an Emergency the Insured

Person should notify Us in writing within 48 hours of

Hospitalization.

• In case of all claims made for treatment at

Out-Of-Network hospittals, the insured will have to

bear 20% co-pay for te amont assessed for the

reimbursement in respect of claim.

• To claim re-imbursements for any Illness or Accident

or medical condition that requires Hospitalization, the

Insured Person should provide us/TPA the documents

listed below, within 15 days of the Insured Person's

discharge from Hospital:

• Specific Waiting Periods: For all Insured Persons,

the conditions listed below will be subject to a

waiting period of 24 months and will be covered in

the third Policy Year as long as the Insured Person

has been insured continuously under the Policy

without any break:

• Gout

• Rheumatism

• Hypertension

• DM

• Varicose veins & Varicose ulcers

• Hemorrhoids (Piles)

• Migraine / Vascular headaches

• Stones in the urinary system

• Stones in billiary system

• Surgery on tonsils / adenoids

• Any type of cysts, nodules, polyps

• Any type of breast lumps

• Treatment of spondylosis/spondylitis - any type

• IVDP & such other degenerative disorders

• Benign Hypertrophic Prostatectomy

• Hysterectomy / Myomectomy done due to Fibroids and/or Mennorhagia

• Heart diseases

• Any type of Carcinoma/sarcoma/blood cancer

• Osteo Arthritis of any joint

• Gastric and duodenal Ulcers

• Thyroidectomy for nodule/multinodular goitre

• Varicocele

• Spermatocele

• Rectal Prolapse

• D&C

• Vitrectomy & retinal detachment surgery for retinopathy

• Amputation due to diabetes

• Fistula in ano

• Fissure in ano

• Her nia

• Hydrocele

• Sinusitis

• Knee / hip joint replacement

• CRF or end stage renal failure

• Cataract

- Duly filled claim form(s) stamped by group (main

policy holder) supported by Investigation test

reports, Original bills, receipts and discharge

certificate/card from the Hospital/ Doctor/Chemists

Doctor's referral letter advising hospitalization in

non-accident cases, the post mortem report (in

case of insured person’s death), First Information

Report (FIR) for medico-legal cases

- Details of any other insurance policy that may

respond to the claim.

We/TPA might request for any other documents or

information that we believe may be required.

Disclosures on Continuity

If a Primary Insured ceases to be Your member/

borrower during the Policy Period, then cover under

the Policy for that Primary Insured and his Dependants

(who are named as Insured Persons in the Schedule)

will immediately and automatically cease unless the

Primary Insured gives Us a written request prior to or

within 5 days of the date of cessation of employment,

to issue a new health insurance policy to himself and

his Dependents (who were named as Insured Persons

in the Schedule) for cover up to his Sum Insured under

the Policy, on payment of premium in full for the new

policy. The Primary Insured understands and agrees

(i) the issue of a new policy shall be subject to Our underwriting requirements, as applicable from time to time, and We may obtain additional information before issuing a new policy;

(ii) We are not bound to continue all terms and conditions of the present cover under the Policy of the Primary Insured and his Dependents under the new policy, however for calculation of waiting periods including for pre-existing conditions under the new policy the time spent by Primary Insured and his Dependants under this Policy may be taken into account, provided new policy is taken without any break from this Policy. Coverage under the new policy shall be available only for the period for

which the premium has been received by Us;

(iii) We are not bound to continue the cover for the

Primary Insured or all his Dependents.

Nomination Facility: Primary Insured can, at the

inception or at any time before the expiry of the Policy,

make a nomination for the purpose of payment of

claims.

How to Buy Max Bupa Swasthya Pratham Micro Insurance Product1. The Micro Insurance Product is sold through all the

direct and indirect channels such as, Agency,

Corporate Agency, DST and Micro Insurance

Agents.

2. Every Customer will be assigned a unique customer

identification number on the Max Bupa system.

3. A Max Bupa proposal form to be completed after

the Customer provides the required information as

stated below :

• Insured’s name, date of birth, designation and address, as necessary.

• As above for all dependants to be covered by the policy.

• Any existing health insurance policy details and claims history, if applicable.

• Selection of Swasthya Pratham Micro Insurance Product sum insured, waivers and

additional cover. • Disclosure of any pre-existing medical

conditions with details. • Medical history report for applicant and

dependants, if necessary. • Signature and date on application, wherever

applicable.

4. All proposals accepted by Max Bupa are internally

processed and enrolled into the Max Bupa system,

and premium payments are cleared.

5. Where proposals are not accepted due to

unacceptable risk then customer too receive

communications from Max Bupa advising of the

same and specific reasons for the cover denied.

Swasthya Pratham - Micro Insurance ProductProduct benefit table

Overall Sum Insured (SI) Rupees

5,000 10,000 20,000 30,000Base Line Cover Benefits (%%)

In-patient treatment (^^^^^^^^^^^^^ ^^^^^^^ ) Doctors’ fees

Diagnostics Tests

Medicines, drugs and consumables

Intravenous fluids, blood transfusion,

injection administration charges

Intensive Care Unit charges

Anaesthesia, Blood, Oxygen,Operation Theatre Covered up to SI Charges, Surgical appliances

Radiotherapy, Cost of Prosthetic Devices,

implants

Medicines and Drugs, Diagnostic Materials and

X-ray, Dialysis, Chemotherapy

Nursing Expenses

Hospital Accommodation General Ward (Boarding Expense)Pre and post hospitalization expenses includingdoctor's consultation, diagnostics tests, medicines, Restricted to Rs.150 per hospilisation or 1.5% of Sum insured ( whichever is higher) (Covered upto per hospitalization liit) drugs and consumables.($$)

Day care procedures-

i. Haemo-Dialysis

ii. Parenateral Chemotherapy

iii. Radiotherapy

iv. Eye Surgery

v. Lithotripsy ( kidney stone removal)

vi. Tonsillectomy

vii. D&C

viii. Surgery of Hydrocele

ix. Surgery of Prostrate

x. Few Gastrointestinal Surgery Covered up to SI xi. Genital Surgery

xii. Surgery of Nose

xii. Surgery of Throat

xiv. Surgery of Ear

xv. Surgery of Urinary System

xvi. Treatment of fractures / dislocation (excluding hairline fracture), Contracture releases and minorreconstructive procedures of limbs which otherwiserequire hospitalization.

xvii. Laparoscopic therapeutic surgeries that can bedone in a day care

Other benefitsAdditional Benefits that can be purchased for extra premium

Overall Sum Insured (SI) Rupees Overall Sum Insured (SI)

5,000 10,000 20,000 30,000Maternity & New Born benefits (**)

Maternity cover for up to 2 deliveries in the entirepolicy period ( Family floater only) Not Available Covered up to Rs.3,000 for Normal and Rs.5,000 for cesareanNew Born Baby Cover Not Available Covered up to SI from day 91 with no extra premium till next renewal

Personal accident ( Death )(&&)

Accidental Death ( only to Adults) Maximum equall 100% of Sum Assured and a minimum of Rs.10,000 per life available only to Adults.OPD

Covers ( ECG,x-ray,Hemoglobin,Blood sugar,Urea,Creatnine ) Upto Rs.500 (per cover under each Certificate of Insurance) in Network Hospital onlyAllowances

Wage Loss Allowances (subject to 48 hours hospitalisation) Rs.100 per day of hospitalization maximum of Rs.700 per cover under each Certificate of InsuranceTransport Allowance (In case of Inpatient Treatmentfor emergency cases only) Max upto 1000 per cover under each Certificate of Insurance and Max 600 Rs per hospitalisationBy Stander Allowance (Subject to 48 hours hospitalisation) Rs.50 per day max of Rs.350 per cover under each Certificate of InsuranceMeal Allowance ( Subject to 48 hours hospitalisation) Rs.30 per day maximum up to Rs.210 per cover under each Certificate of Insurance

Waivers available for Purchase30 day no claim/waiting period from policy inception

24 month waiting period from for Specific Exclusions Available to all groupsPre-existing disease exclusions waivers

(%%) Individual Cover 5,000 -30,000 and Family cover 10,000-30,000 / Family ( insured+spouse+upto 3 kids). Main member age at entry 18-65 years and dependents 3 months to 65 years.There is no exit age.

(^^^^^^^ ^ ) Per hospitalisation limit of 80% of sum insured. ($$) 7days Pre Hospitalisation and 15 Days Post Hospitalisation . (* *) Expenses related to premature delivery ,Pre and Post Hospitalisation would be part of overall maternity cover, (&&) Cover available to only member and his/her spouse. Age 18-65 years only.

- Duly filled claim form(s) stamped by group (main

policy holder) supported by Investigation test

reports, Original bills, receipts and discharge

certificate/card from the Hospital/ Doctor/Chemists

Doctor's referral letter advising hospitalization in

non-accident cases, the post mortem report (in

case of insured person’s death), First Information

Report (FIR) for medico-legal cases

- Details of any other insurance policy that may

respond to the claim.

We/TPA might request for any other documents or

information that we believe may be required.

Disclosures on Continuity

If a Primary Insured ceases to be Your member/

borrower during the Policy Period, then cover under

the Policy for that Primary Insured and his Dependants

(who are named as Insured Persons in the Schedule)

will immediately and automatically cease unless the

Primary Insured gives Us a written request prior to or

within 5 days of the date of cessation of employment,

to issue a new health insurance policy to himself and

his Dependents (who were named as Insured Persons

in the Schedule) for cover up to his Sum Insured under

the Policy, on payment of premium in full for the new

policy. The Primary Insured understands and agrees

(i) the issue of a new policy shall be subject to Our underwriting requirements, as applicable from time to time, and We may obtain additional information before issuing a new policy;

(ii) We are not bound to continue all terms and conditions of the present cover under the Policy of the Primary Insured and his Dependents under the new policy, however for calculation of waiting periods including for pre-existing conditions under the new policy the time spent by Primary Insured and his Dependants under this Policy may be taken into account, provided new policy is taken without any break from this Policy. Coverage under the new policy shall be available only for the period for

which the premium has been received by Us;

(iii) We are not bound to continue the cover for the

Primary Insured or all his Dependents.

Nomination Facility: Primary Insured can, at the

inception or at any time before the expiry of the Policy,

make a nomination for the purpose of payment of

claims.

How to Buy Max Bupa Swasthya Pratham Micro Insurance Product1. The Micro Insurance Product is sold through all the

direct and indirect channels such as, Agency,

Corporate Agency, DST and Micro Insurance

Agents.

2. Every Customer will be assigned a unique customer

identification number on the Max Bupa system.

3. A Max Bupa proposal form to be completed after

the Customer provides the required information as

stated below :

• Insured’s name, date of birth, designation and address, as necessary.

• As above for all dependants to be covered by the policy.

• Any existing health insurance policy details and claims history, if applicable.

• Selection of Swasthya Pratham Micro Insurance Product sum insured, waivers and

additional cover. • Disclosure of any pre-existing medical

conditions with details. • Medical history report for applicant and

dependants, if necessary. • Signature and date on application, wherever

applicable.

4. All proposals accepted by Max Bupa are internally

processed and enrolled into the Max Bupa system,

and premium payments are cleared.

5. Where proposals are not accepted due to

unacceptable risk then customer too receive

communications from Max Bupa advising of the

same and specific reasons for the cover denied.

Swasthya Pratham - Micro Insurance ProductProduct benefit table

Overall Sum Insured (SI) Rupees

5,000 10,000 20,000 30,000Base Line Cover Benefits (%%)

In-patient treatment (^^^^^^^^^^^^^ ^^^^^^^ ) Doctors’ fees

Diagnostics Tests

Medicines, drugs and consumables

Intravenous fluids, blood transfusion,

injection administration charges

Intensive Care Unit charges

Anaesthesia, Blood, Oxygen,Operation Theatre Covered up to SI Charges, Surgical appliances

Radiotherapy, Cost of Prosthetic Devices,

implants

Medicines and Drugs, Diagnostic Materials and

X-ray, Dialysis, Chemotherapy

Nursing Expenses

Hospital Accommodation General Ward (Boarding Expense)Pre and post hospitalization expenses includingdoctor's consultation, diagnostics tests, medicines, Restricted to Rs.150 per hospilisation or 1.5% of Sum insured ( whichever is higher) (Covered upto per hospitalization liit) drugs and consumables.($$)

Day care procedures-

i. Haemo-Dialysis

ii. Parenateral Chemotherapy

iii. Radiotherapy

iv. Eye Surgery

v. Lithotripsy ( kidney stone removal)

vi. Tonsillectomy

vii. D&C

viii. Surgery of Hydrocele

ix. Surgery of Prostrate

x. Few Gastrointestinal Surgery Covered up to SI xi. Genital Surgery

xii. Surgery of Nose

xii. Surgery of Throat

xiv. Surgery of Ear

xv. Surgery of Urinary System

xvi. Treatment of fractures / dislocation (excluding hairline fracture), Contracture releases and minorreconstructive procedures of limbs which otherwiserequire hospitalization.

xvii. Laparoscopic therapeutic surgeries that can bedone in a day care

Other benefitsAdditional Benefits that can be purchased for extra premium

Overall Sum Insured (SI) Rupees Overall Sum Insured (SI)

5,000 10,000 20,000 30,000Maternity & New Born benefits (**)

Maternity cover for up to 2 deliveries in the entirepolicy period ( Family floater only) Not Available Covered up to Rs.3,000 for Normal and Rs.5,000 for cesareanNew Born Baby Cover Not Available Covered up to SI from day 91 with no extra premium till next renewal

Personal accident ( Death )(&&)

Accidental Death ( only to Adults) Maximum equall 100% of Sum Assured and a minimum of Rs.10,000 per life available only to Adults.OPD

Covers ( ECG,x-ray,Hemoglobin,Blood sugar,Urea,Creatnine ) Upto Rs.500 (per cover under each Certificate of Insurance) in Network Hospital onlyAllowances

Wage Loss Allowances (subject to 48 hours hospitalisation) Rs.100 per day of hospitalization maximum of Rs.700 per cover under each Certificate of InsuranceTransport Allowance (In case of Inpatient Treatmentfor emergency cases only) Max upto 1000 per cover under each Certificate of Insurance and Max 600 Rs per hospitalisationBy Stander Allowance (Subject to 48 hours hospitalisation) Rs.50 per day max of Rs.350 per cover under each Certificate of InsuranceMeal Allowance ( Subject to 48 hours hospitalisation) Rs.30 per day maximum up to Rs.210 per cover under each Certificate of Insurance

Waivers available for Purchase30 day no claim/waiting period from policy inception

24 month waiting period from for Specific Exclusions Available to all groupsPre-existing disease exclusions waivers

(%%) Individual Cover 5,000 -30,000 and Family cover 10,000-30,000 / Family ( insured+spouse+upto 3 kids). Main member age at entry 18-65 years and dependents 3 months to 65 years.There is no exit age.

(^^^^^^^ ^ ) Per hospitalisation limit of 80% of sum insured. ($$) 7days Pre Hospitalisation and 15 Days Post Hospitalisation . (* *) Expenses related to premature delivery ,Pre and Post Hospitalisation would be part of overall maternity cover, (&&) Cover available to only member and his/her spouse. Age 18-65 years only.

LITERATURESALES

PROSPECTUSSP