Presentation on

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• Presentation on
• FAMILY HEALTH OPTIMA

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Coverages

• Hospitalization Expenses incurred as an
  inpatient for
• Sickness/Illness/Diseases
• Accident
• For the entire family on floater basis

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Family Means

• Proposer
• Spouse
• Dependent Children

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What is a Hospital ?

• Hospital, Nursing Home means any institution in
  India established for indoor care and treatment
  of sickness and injuries
• It has been registered with the local authorities
  and is under the supervision of a registered and
  qualified Medical Practitioner
• or
• Should comply with minimum criteria as under
• It should have at least 15 inpatient beds (10 in
  Class C Towns).
• Fully equipped operation theatre of its own
  wherever surgical operation is carried out.
• Fully qualified nursing staff under its
  employment round the clock
• Fully qualified Doctor(s) should be in charge
  round the clock.

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Age Limits

• 5 Months 60 Yrs
• Dependent Children can be covered only with any
  one of their Parents

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Sum Insured

• Minimum Sum Insured - Rs. 1,00,000/-
• Maximum Sum Insured - Rs. 5,00,000/-
• The following Sum Insured options are available
• Rs. 1,00,000/-
• Rs. 2,00,000/-
• Rs. 3,00,000/-
• Rs. 4,00,000/-
• Rs. 5,00,000/-

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Allowable Expenses

• Room rent boarding charges as follows
• Class A Cities 2 of the SI or Rs.4000/- per
  day
• (Bangalore, Chennai, Hyderabad, Kolkatta,
  Mumbai including Thane, New Delhi and
  Secunderabad)
• Nursing charges
• Surgeons, Anesthetist, Consultants and
  Specialists fees

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Allowable Expenses (Contd.)

• Operation Theatre charges, drugs and medicines
  diagnostic materials, cost of pace maker etc
• Emergency Ambulance charges to go to Hospital for
  treatment _at_ Rs 750/- per hospitalisation upto
  maximum of Rs 1,500/- per policy period
• Pre-hospitalization expenses incurred 30 days
  prior to the date of hospitalization
• Post hospitalization expenses on a lump-sum basis
  _at_ 7 of the actual hospitalization expenses
  (excluding room rent and hospital registration
  charges), subject to a maximum of Rs 5,000/-

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Day Care Treatment

• Expenses on Hospitalization for minimum period of
  24 hours are admissible. However, this time limit
  will not apply for
• Dialysis,
• Chemotherapy,
• Radiotherapy,
• Cataract surgery,
• Dental Surgery,
• Lithotripsy (Kidney stone removal),
• Tonsillectomy,
• Cutting and Draining of Abscess,
• Liver Aspiration,
• Pleural Effusion Aspiration,
• Colonoscopy,
• Sclerotheraphy,
• taken in the Hospital / Nursing Home and the
  Insured is discharged on the same day.

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Rating
Sum Insured Rs. 1,00,000/- Rs. 1,00,000/- Rs. 1,00,000/-
Age Band 5 Months 45 yrs 46 yrs 55 yrs 56 yrs 60 yrs
2A 1765 NA NA
1A 1C 1515 NA NA
1A 2C 1640 NA NA
1A 3C 1785 NA NA
2A 1C 1890 NA NA
2A 2C 2025 NA NA
2A 3C 2165 NA NA
A Adult C Children upto 25 yrs
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Rating (Contd.)
Sum Insured Rs. 2,00,000/- Rs. 2,00,000/- Rs. 2,00,000/- Rs. 2,00,000/-
Age Band 5 Months 35 yrs 36 yrs 45 yrs 46 yrs 55 yrs 56 yrs 60 yrs
2A 2890 3140 5535 6400
1A 1C 2715 3005 5265 6120
1A 2C 2835 3075 5410 6225
1A 3C 3085 3415 5715 6645
2A 1C 3295 3555 5925 6965
2A 2C 3455 3675 6450 7360
2A 3C 3625 4060 6795 7820
A Adult C Children upto 25 yrs
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Rating (Contd.)
Sum Insured Rs. 3,00,000/- Rs. 3,00,000/- Rs. 3,00,000/- Rs. 3,00,000/-
Age Band 5 Months 35 yrs 36 yrs 45 yrs 46 yrs 55 yrs 56 yrs 60 yrs
2A 3985 4360 7605 10030
1A 1C 3710 3940 6930 9185
1A 2C 3825 4110 7160 9725
1A 3C 4125 4440 7630 10095
2A 1C 4190 4830 7865 10625
2A 2C 4310 5110 8400 11090
2A 3C 4615 5320 8710 11755
A Adult C Children upto 25 yrs
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Rating (Contd.)
Sum Insured Rs. 4,00,000/- Rs. 4,00,000/- Rs. 4,00,000/- Rs. 4,00,000/-
Age Band 5 Months 35 yrs 36 yrs 45 yrs 46 yrs 55 yrs 56 yrs 60 yrs
2A 5195 5565 10510 13515
1A 1C 4750 5070 9660 12730
1A 2C 4910 5250 10150 13210
1A 3C 5365 5725 10980 13755
2A 1C 5295 5775 11270 14290
2A 2C 5645 6240 11870 14890
2A 3C 6025 6540 12585 15815
A Adult C Children upto 25 yrs
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Rating (Contd.)
Sum Insured Rs. 5,00,000/- Rs. 5,00,000/- Rs. 5,00,000/- Rs. 5,00,000/-
Age Band 5 Months 35 yrs 36 yrs 45 yrs 46 yrs 55 yrs 56 yrs 60 yrs
2A 5920 6525 12010 15855
1A 1C 5370 5955 11550 15225
1A 2C 5630 6285 11865 15645
1A 3C 6035 6770 12390 16275
2A 1C 6345 7045 12815 16750
2A 2C 6875 7675 13210 17450
2A 3C 7260 8195 13860 18105
A Adult C Children upto 25 yrs
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Renewal Discount

• 10 Discount on Basic Premium is allowed on
  renewal for every Claim Free Year
• It is not Cumulative

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Other Benefits

• Benefits under Section 80-D of the IT Act
• Cashless Service without intervention of TPA
• Direct Tie up with hospitals on an All India
  Basis
• 24 X 7 In-House Call center
• Toll Free Telephone line assistance
• Full knowledge based website to offer medical
  information, including Health Tips.
• Health Check-up benefits
• Frequent health meets to disseminate info on the
  health related topics

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Exclusions

• Pre Existing Diseases
• Any Disease contracted during first 30 days
• First Year Exclusions
• Benign prostate hypertrophy
• Hernia, Hydrocele, Fistula in Anus, Piles
• Sinusitis
• congenital internal disease/defect
• Renal stone and Gall stone removal
• First Two Years Exclusions
• Cataract
• hysterectomy following menorrhia or fibromyoma
• Knee Replacement Surgery
• Joint Replacement Surgery
• Prolapse of intervertibral
• Vericose veins/ulcers

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Exclusions (Contd.)

• Injury / Disease arising due to War, Invasion,
  Act of Foreign Enemy, Warlike operations
• Circumcision unless necessary for treatment of a
  disease
• Cost of spectacles and contact lens, hearing
  aids, walkers, crutches wheel chairs and such
  other aids
• Dental treatment or surgery
• Convalescence, general debility, Run-down
  condition or rest cure, congenital external
  disease or defects or anomalies, sterility,
  venereal disease, intentional self injury and use
  of intoxicating drugs/alcohol
• Naturopathy Treatment
• Expenses incurred on Lasik Laser or Refractive
  Error Correction treatment

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Exclusions (Contd.)

• Hospital registration charges, record charges,
  telephone charges and such other similar charges.
• Expenses incurred on Non Allopathic Treatment.

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Claim Procedure

• In case of Network Hospitals
• Immediate intimation to the Call Centre (1800 425
  2255)
• The insured has to send a request for Pre
  Authorization Form signed by the Doctor in the
  Network Hospital
• Based on the intimation a field visit will be
  done by the Star Doctor
• Pre Authorization will be issued to the Hospital
• Based on the Pre Authorization and the Report by
  the Star Doctor, Cash Less Treatment will be
  given by the Network Hospital

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Claim Procedure (Contd.)

• In case of Non Network Hospitals
• Immediate intimation to the Call Centre (1800 425
  2255)
• Claim form will be sent to the Insured.
• Based on the intimation a field visit will be
  done by the Star Doctor
• Bills has to be settled by the Insured and will
  be reimbursed by Star on submitting the following
  documents
• Original Discharge Summary
• Main Hospital Bill with Break Up
• Investigation Reports with X-Ray Film
• Medical Bills with Prescriptions

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Thank You