Did You Know ?

1
Did You Know ?

• DID YOU KNOW SERIES

• ON
• HEALTH INSURANCE

2
Is there any need of Health Insurance Planning ?
Yes ! We Need To Plan Against Health
Emergency

• Medical emergencies
• can strike at any time.
• No one of us wants to compromise on the quality
  of medical treatments.

Foundation Must Be Strong !
Emergencies do not come with a Notice
We Need To Be Prepared
3
Healthcare Scenario in India
Increasing population affecting health care
spending and usage. The number of people above 60
yrs is about 8 today, with that number expected
to hit 21 by 2025.

• Changing
• demographics

Increase in incidence of lifestyle-related
diseases and outbreaks of new epidemic and
infectious diseases (H1N1). There is a high
preference for private health care.
Increasing demand
The lack of public infrastructure is attracting
private and foreign investment. Increased
disposable incomes are expected to result in
better healthcare awareness.
Healthcare spending
4
Why We Need to Plan Our Health Insurance ?

• Normal Situation

When medical emergency strikes
Earnings
Expenses
Savings
5
Why to Re-evaluate Our Existing Health Cover ?
Reason I Rise in Treatment costs
Reason II Shift from Infectious To
Lifestyle Diseases
Reason III Shift from Joint Family
to Nuclear Family System
Reason IV Rise in Disposable Income
Reason V Rise in Life Expectancy
6
What is the Inflation in Healthcare Treatment ?

Rise in Health Treatment Cost
No. Treatment Treatment Cost in Year2012 (Approx) Treatment Cost in Year 2007 (Approx ) Increase
1 Cataract 24,000/- 16,000/- 50
2 Angiography 22,000/- 14,000/- 57
3 Coronary Artery By pass Graft (CAGB) 2,35,000/- 1,65,000/- 42
4 Appendectomy 42,000/- 28,000/- 50
5 Heamorrhoidectomy (Piles) 35,000/- 21,000/- 60
6 Cholecystectomy (gall Bladder removal) 52,000/- 32,000/- 63
7 TURP (prostate Surgery) 62,000/- 37,000/- 68
8 Angioplasty (PTCA) with 2 stents 2,45,000/- 1,55,000/- 58
7
Treatment of Serious Ailments Will Soon Become
Unaffordable !
In India Medical Inflation is Rising Alarmingly _at_
14
Major Surgery Current Treatment Cost (Approx) Estimated Treatment Cost After 5 Years Estimated Treatment Cost After 10 Years
1 Knee Replacement ( Once ) 4,00,000 7,70,166 14,82,889
2 Hip Replacement 3,00,000 5,77,624 11,12,166
3 Heart Angioplasty ( Stent ) 3,50,000 6,73,895 12,97,527
4 Coronary Artery Bypass ( Heart Bypass ) 4,50,000 8,66,437 16,68,250
5 Renal Transplant ( Kidney Replacement ) 6,00,000 11,55,249 22,24,333
6 Double Valve Replacement ( Heart Valve ) 4,50,000 8,66,437 16,68,250
7 Liver Transplant 5,00,000 9,62,707 18,53,611
8 Surgery for Tetrology of Fallot ( Heart Surgery) 30,00,000 57,76,244 1,11,21,664
8
Why to Re-evaluate Our Existing Health Cover ?
Shift From Infectious to Life Style
Diseases

• In India , the Burden of Chronic or
  Lifestyle
• Diseases are Exceeding the Infectious
  or
• Communicable Diseases which were
  prominent
• in earlier time.
• Infectious Diseases In earlier time
  Malaria ,
• Typhoid , Hepatitis ,TB , Cholera ,
  Polio ,
• Plague etc , were prominent.
• Lifestyle Diseases Currently diseases
  like
• Diabetes, Hypertension, Coronary Artery
• Diseases (CAD), Tuberculosis, Cholera,
• Kidney Failure, Anxiety, Panic Attacks,
• Immunity Problems , etc are increasing.

9
What are the Causes for Lifestyle Diseases ?
Factors Affecting Lifestyle Diseases
Stress due to long working hours
Increased Commuting Time Increased
Pollution Level Air, Water Noise
Hurried Life Style Habit of Eating
Processed Foods Lack of Sleep Time
10
Which is the Major Factor affecting Lifestyle
Diseases ?
Stress is Majorly Affecting Lifestyle Diseases

• How Our Body System React Under Stress
• Nervous System Signals Glands to release
  Hormones which make Heart
• beat faster
  , raise BP, Change Digestive Process, Boost
• Glucose
  Level in Blood.
• Musculoskeletal System Muscles tense up which
  can trigger Headaches
• Migraines
  etc.
• Respiratory System Stress can cause Rapid
  Breathing which can bring
• Panic Attack
• Cardiovascular System Acute Stress can cause
  increase in Heart Rate ,
• Contraction
  Inflammation of Heart muscles leading
• to Heart
  Attack.
• Gastrointestinal System Stress may Prompt to
  Eat more, increase use of
• Tobacco or
  Alcohol. Stomach can react with Nausea or
• Pain.
  Person can either have Diarrhea or Constipation.

11
Why we need to Re-evaluate Our Family Health
Cover ?
Shift From Joint Family To Nuclear Family
The Responsibility of the Person
having a Nuclear Family increases and he
Needs to Safeguard his Family from
Any Medical Emergency in
Life.
12
Why We need to Re-evaluate Our Health Cover ?
Rise in Personal Disposable Income
When the Disposable Income Increases , One
should Consciously Re-evaluate Health Cover For
Entire Family Considering the Medical Inflation
And Increase the Health Cover Needed.

• Disposable Income is the amount of Money that
  person have
• available to spend save after paying Income
  Tax and pension
• Contribution. The revenue may include Property
  Income ,
• Employees Compensation , Income from other
  sources .

13
Why Long Term Planning required for Health
Insurance ?
Rise in Life Expectancy
In India, the Average Life of an individual has
increased due to the Advanced Research and
Technology in Medical Science . The possibility
of an early Death can be either due to an
Accident or any Critical illness.
One should have
Sufficient Health Cover against any Critical
illness after the Retirement Age.

• May 16, 2011 Kounteya Sinha
• NEW DELHI An average Indian (factoring
  in both genders) lived eight years longer in
  2009, compared to two decades ago. However, that
  figure was still three years less than the global
  average life expectancy (LE). An average Indian
  woman lived three years more than her male
  counterpart in 2009. While a woman lived for 66
  years, the LE of an Indian man stood at 63 years.
  
• Source Times Of India

14
Which cant be Ignored!
Lack of Awareness Negligence can Create a
Disaster !
16 percent of Indians are being pushed into
poverty by rising health care costs. About 40
percent of the people hospitalized have to borrow
money or sell assets to cover expenses.
Source The World Health Organizations 2006
survey
15
Which cant be Ignored !

• In India , the Number Of Hospitals per 1000
  persons is 0.7 , where as World Average is 3.9
  per 1000 .
• Due to Poor Facilities in Govt. Hospitals in
  India 80 of Medical Services are provided by
  Private Sectors making Treatment Unaffordable to
  Common Man.
• 85 of Indians , Do not have any Health
  Insurance Cover or they are Under covered.
• 30 of People who suffer Heart Attack are
  Affected Before the Age of 40 Years.
• India is the Diabetic Cardiac Capital of the
  World .
• 9 Crore Diabetics in India by 2025.
• Over 8 lac People Die of Cancer Every Year in
  India.
• More than 7 Lac New Cancer Cases Diagnosed in
  India Every Year.

Facts do not Cease to exist Because they Are
ignored !
16
Healthcare Spends Across Ages

There are Different Needs For Different Age
Groups
Age Band Medical Expenses
0 20 Years Vaccination , Hospitalization for Various illness , Accidental Care
20 40 Years Hospitalization , Accidental Care , Maternity Care , Health Check-up , Critical Illness
40 60 Years Critical illness , Health Check-up , Hospitalization for Various illness , Accidental Care
60 Years Above Critical illness , Health Check-up , Senior Citizen Care , Accidental Care
17
How to Choose Health Insurance Plan ?

Features One should consider

• Actual Cover Required , depending on
  Age Family History
• Cashless Facility at Quality Hospitals
• Free Medical Check up at Regular Intervals
• Availability of Maternity and Child Care
  Benefits
• All the Day Care procedures should be Covered
• No Age restriction for Enrolment
• Flexibility Option to Top up the Existing
  Cover
• with Affordable Price
• Cover for Pre Post Hospitalization
• Guaranteed Renewability for Lifetime
• Quick Transparent Claim Process

18
How to Understand Terms used by Health
Insurance Companies ?

• Pre-Hospitalization Expenses
• Medical Expenses incurred Prior to
  Hospitalization like Doctors Consultation Fees ,
  Medicine Expenses , Expenses towards Medical
  Tests like X-ray, Zoography, Blood Tests,
  etc.
• Generally the period for
  Pre-Hospitalization is 30 days .
• Post-Hospitalization Expenses
• Medical Expenses incurred after
  Hospitalization to determine the Recovery
  Progress of the Discharged Patient.
• for eg. Cost of Medicines, Doctors
  Consultation ,
• Diagnostic Tests Expenses towards
  Medical
• Support Equipments etc.
• Generally the period for
  Post-Hospitalization is 60 days .

Terminology
19
How to Understand Terms used by Health Insurance
Companies ?

• Inpatient Treatment
• The Treatment provided to the Insured upon
  Admission To a Hospital for More than 24 hrs on
  the Written Advice of a Medical Practitioner.
• Includes Room Charges, Drugs, Nursing
  Expenses, ICU Charges, Surgeons Fees,
  Anesthesia, Blood, Oxygen, Operation Theatre
  Charges , Pathology Tests , Prosthetic
  Implants, Diagnostic Tests Therapies , etc.
• Day Care Treatment
• The Treatment provided to Insured upon
  Admission
• to a Hospital for less than 24 hrs on the
  written
• Advice of a Medical Practitioner.
• For eg. - Treatments like Kidney Stones, Eye
  Cataract ,
• Chemotherapy, Radiations, Dialysis, Lithotripsy
  , etc.

Terminology
20
How to Understand Terms used by Health Insurance
Companies?

• Max Renewable Age
• It is the Age to which the Insurance
  Company would continue to Provide the Health
  Insurance Cover on Payment of the premium.
• Health Insurance Company that Offers
  Assured Policy Renewal for Life are
  Considered Favorable.
•   Cashless Hospitalization
• The insured gets the Required Treatment
  while the Medical Expenses are Settled by the
  Insurance Company directly with the Hospital (if
  the Hospital comes under the Network Tie up
  List provided by the Insurance Company ,
  subject to the
• Terms Conditions mentioned in the
  Policy ).
• To avail Cashless Treatment, the
  Customer Needs to Obtain Cashless Approval
  from the Insurance Company.
•  

Terminology
21
How to Understand Terms used by Health Insurance
Companies?

• Pre- Existing Diseases
• Disease such as Diabetes , BP, Heart
  Disease, etc. that a Person is already
  suffering from ,
• at the time of Purchasing the Policy
  are Termed as Pre-existing Diseases.
• a
• Insurance Companies do take the Risk of
  Covering these Pre-existing Diseases with
  certain Conditions.
• a
• Insurer may cover after Charging
  Additional Premium Or after a specific
  Waiting Period Maximum up to 48 months .
• .
•  

Terminology
22
How to Understand Terms used by Health Insurance
Companies?

• Organ Donor Coverage For most of the
  Health Insurance Policies it is considered to be
  an Exclusion. There are some Insurers who are
  keen on Covering Organ Donors Expenses with an
  Inbuilt Cover.
•  
•  

COMPANY ORGAN DONOR COVER
Religare Covered up to 3Lac as per Plan
LT Covered
New India Not Covered
Apollo Munich Covered
Bajaj Allianz Not Covered
ICICI Lombard Not Covered
Max Bupa Covered
Star Health Not Covered
Terminology
23
How to Understand Terms used by Health Insurance
Companies?

• Domiciliary Treatment It is the Treatment
  carried out at Home due to Lack of
  Accommodation in Hospital / Nursing Home or
  Patients Condition is such that he/she can
  not be Shifted to the Hospital for the
  Treatment. This requires Treating Doctors
  Recommendation.
•  
•  

COMPANY DOMICILIARY TREATMENT COVER
Religare Covered up to 10 of Sum Insured
LT Covered , Min. 3 Days Treatment Require
New India Not Covered
Apollo Munich Covered
Bajaj Allianz Not Covered
ICICI Lombard Not Covered
Max Bupa Covered
Star Health Not Covered
Terminology
24
How to Understand Terms used by Health Insurance
Companies?

• E- Opinion / Second Opinion There are
  some Health Insurance Cos. Who offer the
  Policy Holder to Obtain a Second Opinion from
  their Medical Panel Experts for some
  Listed Critical illness suffered during Policy
  Year.
•  
•  

COMPANY SECOND OPINION BENIFITE
Religare Covered
LT Not Covered
New India Not Covered
Apollo Munich Covered
Bajaj Allianz Covered FOR SI more than 5 Lac
ICICI Lombard Not Covered
Max Bupa Covered
Star Health Not Covered
Terminology
25
How to Understand Terms used by Health Insurance
Companies?

• Co-Payment After certain Age , a
  Policy Holder have to Share some of the Total
  Claim Amount with Health Insurance Company and
  Pay from his Pocket .

COMPANY CO-PAYMENT CONDITION
Religare No Co-Payment if Issued before 61 Yrs
LT No Co-pay
New India Co-Pay Condition Apply
Apollo Munich No Co-Pay
Bajaj Allianz No Co-Pay
ICICI Lombard No Co-Pay
Max Bupa Co-Pay _at_ 20 after 65 Years of Age
Star Health Co-Pay Condition Apply _at_ 20 - 30
Terminology
26
How to Understand Terms used by Health Insurance
Companies?

• Loading It is the Amount Charged by
  Health Insurance Company on Renewal Premium
  when Claim is made in the Policy .
•  
•  

COMPANY LOADING ON CLAIM
Religare No Loading
LT No Loading
New India Loading on Claim
Apollo Munich No Loading
Bajaj Allianz Loading up to 50 on Claim
ICICI Lombard
Max Bupa No Loading
Star Health No Loading
Terminology
27
How to Understand Terms used by Health Insurance
Companies?

• Network Hospitals These are Hospitals
  Nursing Homes which are Associated with the
  Insurance Company . Cashless Claim is
  Facilitated
• through this Network of Hospitals .
•  
•  

COMPANY CASHLESS HOSPITAL TIE-UP
Religare 1700 Network Hospital Tie-up
LT
New India TPA Managed
Apollo Munich 4500 Network Hospital Tie-up
Bajaj Allianz 2300 Network Hospital Tie-up
ICICI Lombard 4000 Network Hospital Tie-up
Max Bupa
Star Health 4900 Network Hospital Tie-up
Terminology
28
Does Your Insurance Company Provide Free Health
Check-up ?

• Health Check-up Preventive Health
  Check-ups are very Useful in Early Detection
  of any Type of illness and Risk Factors .
  There are many Insurance Companies which Offer
  Free Health Check-up to the Policy Holders at
  Regular Intervals at their Network
  Diagnostic Centers.
•  
•  

COMPANY HEALTH CHECK-UP BENIFITE
Religare Annual Health Check-up
LT After 2 Years of Renewals
New India After 4 Claim Free Years
Apollo Munich After 2 Claim Free Years
Bajaj Allianz After 4 Claim Free Years
ICICI Lombard Annual Health Check-up
Max Bupa Annual Health Check-up
Star Health No Health Check-up
Terminology
29
What are the Diseases which are not Covered under
your Policy?

• Permanent Exclusions The Insurer
  shall not pay Policy Holder , the Claim for
  Some Cases such as
• Non-allopathic Treatment
• Self-inflicted injury resulting from Suicide or
  any attempt of Suicide.
• Cost of Contact Lenses/ Spectacles
• Dental Treatment
• Medical Expenses resultant of Alcohol/ Drugs
• Medical expenses for Treatment of AIDS
• Congenital Disease
• Cosmetic Obesity Treatments
• Treatment related to HIV or AIDS
• Sexual Problems , Miscarriage or Abortion
• Infertility Test Treatment etc.
•  

Exclusions
?
30
Can Maternity Expenses be Covered in Health
Insurance Policy?

• Maternity Cover This include Hospital
  Expenses , Baby Delivery Charges for any kind of
  Delivery , New Born Coverage ,Vaccinations Post
  Care Expenses . Maximum of Two Deliveries are
  covered. The Coverage amount depends on SI .
•  
•  

COMPANY MATERNITY BENIFITE
Religare Not Covered
LT Covered , Waiting Period of 2 Years
New India Not Covered
Apollo Munich Covered , Waiting Period of 6 years
Bajaj Allianz Not Covered
ICICI Lombard Not Covered
Max Bupa Covered , Waiting Period of 2 Years
Star Health Not Covered
Maternity Cover
31
What is the Benefit to Policy Holder for a
Claim Free Year ?

• No Claim Bonus When a Renewal is made in
  a Health Insurance Policy without any Claim in
  the Preceding Period of the Policy , the
  Insurer offers Bonus to the Policy Holder.
  The Bonus can be added to the Sum Assured at a
  pre decided Rate.
•  
•  

COMPANY NO CLAIM BENIFITE
Religare 10 every yr , max up to 50
Religare Care with Super NCB 10 every yr ,max up to 50 Add on NCB 50 ( (Two Claim free yrs) Total NCB max 150 of SA
New India 0 NCB , discount offered in Renewals
L T 10 subject to Max. 50
Bajaj Allianz 10 subject to max 50
Max Bupa 10 Loyalty Benefits Voucher
Star Health 5 subject to max 25
Terminology
32
Can We Switch Our Existing Health Policy To Other
Insurer ?

• Portability
• It allows Policyholders to Switch their
  Health Insurance
• policy from One Insurer to another and
  Carry Forward
• the Waiting Period and No Claim Bonus
  Entitlement
• of the Existing Policy.
•  

• Policy Start Date of Portability
• It is calculated as Later of following
• Expiring Policy End Date 1
• Proposal Receipt date at Branch 1
• Cheque Date.

• Documents Required for Portability
• Duly Filled Proposal Form
• Duly filled Portability Form
• Premium Cheque
• Expiring Policy Copy
• Renewal Notice from Existing Insurance Company
• No-Claim Declaration

33
Which are the Areas Where Insurance Companies
do Capping ?

• SUB LIMIT It is Capping on the Amount for the
  Particular Benefit provided by the Co.
• SUB-LIMIT on ROOM RENT Some Insurance
  Companies have put
• limits for the Room Charges when Claim is
  Settled.
•  

COMPANY SUB LIMIT ON ROOM RENT
Religare Single Private Room for SI above 5 Lac
LT 1 of Sum Insured
New India 1 of Sum Insured
Apollo Munich
Bajaj Allianz 1 of SI , Max. up to 30 of SI/illness
ICICI Lombard
Max Bupa Single Private Room for SI above 5 Lacs
Star Health
Sub-Limit
34
Which are the Areas Where Insurance
Companies do Capping ?

• SUB-LIMIT on ICU Charges Some Insurance
  Companies have put Limits in the Policy for ICU
  Charges when Claim is Settled.
•  

COMPANY SUB LIMIT ON ICU CHARGES
Religare No Sub-Limit for SI above 5 Lacs
LT 2 of Sum Insured Per Day
New India 2 of Sum Insured Per Day
Apollo Munich No Sub-Limit
Bajaj Allianz 2 of SI , Max. up to 30 of SI/ illness
ICICI Lombard
Max Bupa No Sub-Limit
Star Health No Sub-Limit
Sub- Limit
ICU
35
Which are the Areas Where Insurance
Companies do Capping ?

• SUB-LIMIT on Surgeon , Anesthetist
  Specialist Fees
• Some Insurance Companies have put limits
  for the Charges paid to the Medical
  Professionals when Claim is Settled.

COMPANY SUB LIMIT ON PROFESSIONAL FEES
Religare No Sub Limit
LT No Sub Limit
New India 25 of Sum Insured Per Claim
Apollo Munich No Sub Limit
Bajaj Allianz Up to 30 of Sum Insured Per Illness
ICICI Lombard
Max Bupa No Sub Limit
Star Health No Sub - Limit
Sub-Limit
36
Which are the Areas Where Insurance
Companies do Capping ?

• SUB-LIMIT Operation Theater, Anesthesia
  , Blood Oxygen Charges
• Some Insurance Companies have put limits
  on the Charges for
• Operation Theater , Anesthesia , etc.
  when Claim is Settled.
•  

COMPANY SUB-LIMIT ON OT, Anesthesia , etc.
Religare No Sub Limit
LT No Sub Limit
New India
Apollo Munich No Sub Limit
Bajaj Allianz Up to 40 of Sum Insured Per Illness
ICICI Lombard
Max Bupa No Sub Limit
Star Health No Sub - Limit
Sub-Limit
37
Which are the Areas Where Insurance Companies
do Capping ?

• SUB-LIMIT on Specific Diseases There
  are certain Ailments such as Cataract , Piles
  , Knee Replacement etc. Which are not Covered
  for Specific Period , but can be Covered
  Subsequently .
•  

COMPANY SUB LIMIT FOR CATARACT
Religare No Sub - limit
LT No Sub Limit
New India Rs. 24,000/-
Apollo Munich No Sub Limit
Bajaj Allianz 10 of SI or 12,000/- whichever Low
ICICI Lombard
Max Bupa No Sub - Limit
Star Health Rs. 12,000/- to 30,000/- as per Plan
Sub-Limit
38
Which are the Areas Where Insurance Companies
do Capping ?

• SUB-LIMIT on Ambulance Charges Some
  Insurance Companies have put limits for Ambulance
  Cover when the Claim is Settled.

COMPANY AMBULANCE COVER
Religare 1500/- TO 3000/- per Claim as per Plan
LT Rs. 1500/- per Claim
New India 1 of SI , Max. Rs. 2500/-
Apollo Munich Up to Rs. 2000/- per Claim
Bajaj Allianz Rs. 1000/- per Claim
ICICI Lombard
Max Bupa At actual for Network Hospitals , Rs. 2000/- Non Network Hospitals
Star Health Rs. 750/- per Claim, 1500/- per Policy
Sub-Limit
39
How to Handle Health Insurance Claim ?

• CLAIM When an Insured suffers a Loss or Damage
  
• that is Covered in the Health
  Insurance
• Policy, The Insured can collect on
  the
• Proceeds by Filing a Claim.
• CLAIM PROCESS Each Every Health Insurance
• Company have Their Own Procedure to
  
• Process the Claim and TAT i.e.
• ( Turn Around Time )
• TYPES OF CLAIM SETTLEMENT
• 1.Cashless
• 2. Reimbursement
•  

40
What is Cashless Claim Settlement Health
Insurance ?

• CASHLESS CLAIM SETTLEMENT
• This Facility Enables Insured To Avail
  The Treatment Without Paying Hospital Bill. The
  Insurer Or Third Party Administrator ( TPA )
• Will Settle On Your Behalf. The Only
  Condition
• Is That The Hospital Should Be under The
  Network Hospital List Of Insurer.
• ADVANTAGES OF CASHLESS FACILITY
• Cashless Facility Reduces Financial Burden to the
  Policy Holder.
• It Helps as Everyone Does Not Have Immediate
  Liquid Cash To Pay Hospitalisation Expenses.
   

CASHLESS CLAIMS
41
What is Cashless Procedure in Planned
Hospitalization ?

• PLANNED HOSPITALISATION Here The Patient is
  Aware That He Has to Get Admitted in Few Days
  Have Time To Decide Network Hospital.
• CASHLESS PROCEDURE
• Collect Pre-authorisation Form from Hospital
  Insurance Help Desk and Submit at least Before
  3-4 Days in Advance
• Fill the Relevant Details For Other Details
  Related to Injury Can Be Filled By Attending
  Physician Of The Hospital .
• Person At The Help Desk Verifies And
  Forwards To Insurer/TPA
• Depending on Terms of Policy , Insurers Claim
  Department / TPA Will Issue an Authorisation Or
  Denial Letter to the Hospital Also Spell Out
  the Expense Limit .
• If it is Approved , Treatment up to Admissible
  Limits will be Processed
• The Final Bill is Settled After the Full
  Treatment
• In Some Cases Treatment Exceeds the Sum Assured ,
  than One has to pay for Excess amount.

42
What is Cashless Procedure in Emergency
Hospitalization ?

• EMERGENCY HOSPITALISATION Here Patient is to Get
  Admitted Under Emergency. One must Apply for
  Cashless Facility Max. within 24 Hrs.
• CASHLESS PROCEDURE
• Pre-authorization Form Avilable from Hospital
  Insurance Help Desk .
• Fill the Relevant Details Other Details can be
  Filled by attending Physician , Must Carry Health
  Card Policy along With You.
• Person at the help desk verifies and forwards to
  Insurer/TPA
• According to Protocol , Insurer must process
  within 6 Hours
• Depending on Policy Terms , Insurer/TPA will
  Issue an Authorization Or Denial Letter to the
  Hospital also Spell Out the Expense Limit .
• If it is Approved , Treatment up to Admissible
  Limits will be Processed
• The Final Bill is Settled After the Full
  Treatment
• If Cashless Approval is not given , One Can Pay
  the Bill and Submit Documents for Reimbursement

43
What is Not Covered Under Cashless Claim Policy
?

• THINGS NOT COVERED UNDER PA POLICY
• VISITOR FEES.
• REGISTRATION FEES
• COST OF ITEMS LIKE Adult Diapers ,
  Oxygen Masks , Tena Pads , Nebulizers , etc.
• DOCUMENT CHARGES
• TOILETORIES
• SERVICE CHARGES

NOT COVERED UNDER POLICY
44
What Are The Points To Remember For Cashless
Procedure?
DID YOU KNOW ?

• POINTS TO REMEMBER FOR CASHLESS CLAIMS
• Cashless Service Offered by Insurer Only in
  Network Hospitals
• Ensure with The Hospital Help Desk , If It is
  Under Insurers Network List
• Pre-Authorisation Process For Planned
  Hospitalization Must be Made 3-4 days in
  Advance
• Pre-Authorisation For Emergency Hospitalisation
  must be within 24 Hours
• At the Time of Admission Carry Health Card
  Policy Copy .
• If Pre-authorization Form is Incomplete , it may
  Delay Cashless Approval
• Generally it is Hospitals Responsibility to
  Provide Justification For the Treatment while
  filling Pre-authorisation Form.
• All Documents such as Pharmacy Bills, Lab Reports
  etc. must be Submitted to the Hospital before
  Discharge.
• Always keep a Copy of above mentioned Documents
  Submitted .
• In some cases Insurer Does Not Accept Cashless
  Claim , then you can Apply for Reimbursement.

45
We need to Inform Health Insurance Co. for Any
Claim

• CLAIMS INTIMATION
• In Case Of Hospitalisation Intimation Must
• Be Given On The Same Day Of The
• Hospitalization Within 24hrs On The Toll
  Free Number / Mail id Provided By The Insurer.
  
• Information Required for Claim Intimation
• Insured Name
• Policy No . Policy Period
• Claimant/Patient Name
• Hospital Name Address
• Cause/Diagnosis
• Date of Admission
• Name of Doctor Treating the Patient
• Contact details of the Hospital
•  

CLAIM INTIMATION
46
What Documents Required for Health Claim
Reimbursement ?

• CHECK-LIST For CLAIM REIMBURSEMENT
• Original Claim Form duly Filled signed by
  Beneficiary .
• Member ID Card No. issued by Company / TPA .
• Complete Set of Policy Copies for the
  Current Year Previous Year .
• Original Discharge Summery / Discharge Card
  OR
• Day Care Summery / Card in case of Daycare
  Treatment .
• Original Death Summery ( In case of Death
  Claims )
• Original Hospital Pre-printed Numbered Bill
  with the Detailed Break- up of Charges Levied
  under various
• Head such as Room Rent, Operation Theater
  Charges, Nursing Charges , Pharmacy Charges ,
  etc.
• 
  
• ..To Be Continued
•  

CHECK-LIST
47
What are the Documents Required for Claim
Reimbursement ?

• CHECK-LIST For CLAIM REIMBURSEMENT
• Original Payment Receipt ( Pre-printed and
  Numbered) of the Hospital ( Revenue Stamp
  Compulsory for the Payment made more or equal to
  Rs 5000)
• Original Pharmacy Bills with Batch Nos. and
  Treating Doctors Prescriptions
• Original Investigation Bills along with
  Diagnostic Reports supported by Doctors
  Prescriptions.
• First Consultation Note / Admission Note from
  Doctor.
• Treating Doctors Certificate regarding detailed
  cause of Accidental Injury.
• Indoor Case Papers duly Attested by Doctors
  Signature and Stamp.
• 
  ..To Be Continued
•  

CHECK-LIST
48
What Are the Documents Required for Claim
Reimbursement ?

• CHECK-LIST For CLAIM REIMBURSEMENT
• In Case Of Cataract Surgery , Original IOL
  Sticker
• ( Intraocular Lens) is Required Along
  With Invoice .
• In Case of Implant Surgeries Such as Heart
  Valve,
• CABG , Knee Replacement , Abdominal
  Surgeries ,
• etc. Please Provide Tax Invoice For
  Prosthetic Device Used Along with Barcode
  Number and sticker .
• Police FIR / Medico Legal Certificate ( MLC )
  Is To Be Submitted Where Ever Applicable , For
  eg. Road Accidents, Serious Injuries etc.
• NEFT Form Duly Filled and Cancelled Cheju With
  IFSC Code , Bank Passbook Copy.
• In Case Of Claim Amount More Than Rs. 1 Lac,
  Then
• Photo ID proof Address Proof is must.
• 
  
•  

CHECK-LIST
49
What are the Tips for Faster Health Claim
Settlement ?

• USEFUL TIPS FOR FAST CLAIM SETTLEMENT
• Intimate the Claim within 24 Hours of
  Hospitalization
• For Claim Reimbursement , submit the Documents
  within Seven Days after the Discharge from
  Hospital.
• Please Retain Copies of all the Documents
  submitted to the Insurer for Future Reference.
• Always Fill the NEFT Form and Provide Cancelled
  Cheque with IFSC code along with Bank Passbook
  copy so that the amount is directly
  Credited to your Bank Account.
• In case of Deficiency raised by Insurer , please
  provide the Required Documents ASAP.
• Claim Files are Closed/ Repudiated on
  Non-submission Or Delay in Submission of
  documents.
• For Faster Disposal of Claim , if possible
  enclose the Complete Set Of Policies Of Last 2
  - 4 Years.
• 
  
•  

50

DID YOU KNOW ?

• .
• 
  
• GROUP MEDICAL INSURANCE
• GMC

51
What is Group Medical Insurance ?
DID YOU KNOW ?

• GROUP MEDICAL COVERAGE
• It is an Insurance Plan which Provides Healthcare
  Cover for a Selected Group Of People .
• These Plans are Generally Uniform in nature,
  offering the same Benefits to all the members of
  the Group.
• This Plan are Majorly Offered By Employers To
  Employees , Association To Members , Or
  Community Group To Their Members, etc.
• These Insurance Plans Costs Less Than Individual
  Plans which Offer the Same Benefits , as the Risk
  is Spread Over the Entire Group , Rather than an
  Individual or One Family.
•  

52
Why Companies Offer Group Medical Insurance To
Employees ?
DID YOU KNOW ?

• PURPOSE OF GROUP HEALTH INSURANCE
• Todays Work Environment is Full Of
  Competition Pressure Of Performance .
• Health is One Of The Biggest Issues That
  Challenges Both Employee Employer .
• Showing Concern About an Employees His
  Familys Health and Sending out the Message that
  Health Comes First is the Best Motivation an
  Employer can Provide.
• Also Companies Provide Health Cover in the View
  Of Better Health Gives , Higher Productivity .
•  

53
What Are The Benefits To Employee Employer
If Offered GMC ?
DID YOU KNOW ?

• BENEFITS OF GROUP MEDICAL
  INSURANCE
•  

BENEFITS TO EMPLOYEE BENEFITS TO EMPLOYER
Reduce Out of Pocket Medical Cost Good Employee Welfare Gesture
Financial Peace Of Mind Better Health Higher Productivity
Lower Premium Rates Attract Retain Key Talent
Access To Quality Hospitals High Employee Morale
Coverage Available For Parents Parents in Laws Checks Absenteeism
No Medical Underwriting Required for Certain Coverage. Tax Savings
Tax Saving If Premium Deducted From Salary . Administrative Ease
54
GROUP MEDICAL COVER V/s INDIVIDUAL HEALTH
COVER
DID YOU KNOW ?

•  

GROUP MEDICAL INSURANCE INDIVIDUAL HEALTH INSURANCE
GMC is Less Expensive One Pays More For Individual Cover
Medical Tests not Mandatory Medical Tests Compulsory
Contract in Name of Company Contract in Name of Individual
Tailored Coverage , Controlled or Cancelled by Company Anytime Individual Can Customize as per Need and Requirement.
Coverage May not be Enough Considering Medical Inflation Individual Can Enhance Coverage with Rising Treatment Costs.
Coverage Ends when Person Leaves Organization Individual is Protected whenever He Changes Organization.
Coverage Ends/Limited Cover When Retired Individual is Protected Even After He is Retired
55
Does Anyone Require Additional Cover If He Is
Covered Under GMC ?
DID YOU KNOW ?

• In Group Medical Insurance , Members Of the Group
  or Company are Provided with a Certain Fixed
  Uniform Cover. There may be Co-Payment Clause for
  the Employee.
• The Company Management may Change the Insurer or
  The Product which may not Suit Individual
  Requirement.
• Cover Offered in GMC , May not be Sufficient with
  Rising Inflation In Medical Treatment Cost.
• The Members are Covered Till The Time They Are
  Part Of The Group . The Coverage is Removed
  when Person Leaves The Group.
• When a Person has Resigned the Company and After
  Some Period Has To Join New Organization . During
  this Job Transit, Person is Unprotected if some
  Medical Emergency Arises.
• One Should Have Individual Health Cover in
  Addition to GMC.
•  

56

DID YOU KNOW ?

• .
• 
  
• PERSONAL ACCIDENT INSURANCE

57
Accidents Can Happen ..Anywhere..Any Place..By
Anybody

• .
• 
  

AIR
ROAD
RAIL
WATER
NATURAL CALAMITIES
TERRORISM
ANIMAL BITE
SLIPPING
58

Hard Facts Which Cant be Ignored

• ACCIDENTS IN INDIA
• 72 Accidents are Reported Every Hour
• 38 Deaths Occur Every Hour due to Accidents .
• 1.2 Lac People Died in Accidents in Year 2008.
• 70 Death due to Accidents in the Age Group of
  15 yrs 44 yrs.
• Source National Crime
  Record Beauro

Facts do not Cease to exist Because they Are
ignored !
59
What is Personal Accident ( PA ) Insurance ?

• PERSONAL ACCIDENT INSURANCE
• It is the Cover , in the Event of a
  Person Sustaining Bodily Injury Resulting
  Solely Directly from an Accident
  Caused by External, Violent Visible Means,
  Resulting
• In To Death Or Disablement ( Total /
  Partial ) , And Does Not Include Any Illness /
  Disease.
• 
  
•  

60
Why One Need Personal Accident Insurance ?

• Unfortunate Event Can Happen To Anyone ,
  Anywhere
• Anytime.
• Every Individual is Exposed to Various Kind of
  Risks.
• A Damage Caused By Personal Accident Can
  Be Good Enough
  To Burden any Individual Financially.
• Most Individuals Prefer Having Life Health
  Insurance . Life Insurance Only
  Covers Death While Health Insurance
  Covers Hospitalization. PA Riders Are Not
  Comprehensive
• It is Better To Have Standalone Personal
  Accident Policy.
• Personal Accident Cover is a Potential Hedge
  Against Unforeseen Events in Life.
  It is wise to Ensure Protection
  Against Accidental Risks That One May Come
  Across In Life.
• Now a Days, Chances of Death Or Getting
  Hospitalization For illness is Lower Than
  Chances of Meeting An Accident !
•  

61
What is Covered Under Personal Accident
Insurance ?

• COVERAGE
• Rail / Road / Air Accident
• Injuries due to any collision
• Slipping from Stairs or in Bathroom
• Fractures Burns
• Injury due to Drowning
• Poisoning
• Animal Bite etc.
•  

62
What Are Features of Personal Accident
Insurance ?

• STANDARD FEATURES
• Accidental Death
• Permanent / Partial Disablement
• Temporary Total / Partial Disablement
• ADDON BENEFITS OFFERED IN PA POLICY
• ? Medical Expenses ? Corrective Surgery
• ? Hospitalization Benefits ? Funeral Expenses
  
• ? Compensation for Income loss ? Worldwide
  Cover
• ? Act of Terrorism Cover ? Child Education
  Benefit
• ? Personal Loan Protection Following
  Accidental Death Permanent Total Disability
•  

63
What is Not Covered Under Personal Accident
Policy ?

• EXCLUSIONS UNDER PA POLICY
• Intentionally/Self-inflicted Injury/Sickness
• Suicide or Attempt of Suicide .
• Injury / Death While On Active Duty In Armed
  Forces .
• Sickness , Disease, Pregnancy, Childbirth ,
  Miscarriage , Bodily Infirmity Or Bacterial
  Infection Other Than An Inflation From
  Accidental Cut / Wound .
• Driving Under Influence Of Alcohol Or
  Intoxicating Drugs
• Dangerous Sports
• Voluntary Involvement in Riots
• Disease Or Infection Caused Before Accident

64
What are the Types Personal Accidental Policies?

• TYPES OF PA POLICY
• 1. INDIVIDUAL PA POLICY
• This Policy Can Be Availed By Any
• Individual For Self Protection .
• FAMILY PA POLICY
• Any Individual Can Take This Policy For
  The Protection Of His Family .
• GROUP PA POLICY
• It Can Be Availed By A Group Of
  Employees
• Of An Organization and Their Dependents
  ,
• Member Of Clubs , Society Members And
  
• Associates , etc.

65
What are the Important Terms in PA Policies?

• ACCIDENT
• A Sudden Unforeseen And Unexpected Event
  Caused By External , Violent Visible Means
  ( But Not Include Any illness or Disease )
  which Results in Physical Injury But Not
  Include Mental , Nervous or Emotional Disorders
  , Depression
• Or Anxiety.

TERMINOLOGY
66
What are the Important Terms in PA Policies?

• ACCIDENTAL DEATH
• Death Caused In An Accident And Not Due To
  Any Natural Cause is Claimed As An
  Accidental Death.
• ACCIDENTAL BODILY INJURY
• Any Injury Caused By Accident Which
  Occurs During Policy Period , But Does Not
  Include Sickness , Illness Or Disease.

TERMINOLOGY
67
What are the Important Terms in PA Policies?

• PERMANENT TOTAL DISABLEMENT
• Any Accidental Injury Resulting Into
  Loss Of Any Two Limbs Or Permanent Complete
  Loss Of Sight in Both Eyes Or Injuries That
  Render The Person Not Capable Of Earning an
  Income And is Certified By a Medical Specialist
  That the Injury is Permanent in Nature , It is
  Termed as Permanent Total Disablement.

TERMINOLOGY
68
What are the Important Terms in PA Policies?

• PERMANENT PARTIAL DISABLEMENT
• Any Accidental Injury Resulting into
  Permanent Loss of Any Body Part , One Eye , One
  Limb, or One Finger Or a Toe And is Certified
  By a Medical Specialist That The Accidental
  Injury is Of a Permanent and Partial Nature , it
  is Termed as Permanent Partial Disablement.
  The Loss May be Permanent , But its
  Effect On the Person and His Life are Partial.

TERMINOLOGY
69
What are the Important Terms in PA Policies?

• TEMPORARY TOTAL DISABLEMENT
• Any Accidental Injury That
• is Not Permanent in Nature , Making an
  Injured Person Completely Unable to Perform Any
  Job Functions On A Temporary Basis And is
  Certified By a Medical Specialist That the
  Injury is Of a Temporary in Nature , And The
  Person is Unfit to Work is Termed as Temporary
  Total Disablement.

TERMINOLOGY
70
What are the Classification of Risks in PA
Policies?
Risk Levels Determined By The Occupation Of The
Person
RISK LEVEL I RISK LEVEL II RISK LEVEL III
Persons Engaged In Administrative and Managing work, Professionals Such as Accountants, Doctors, Lawyers, Architects , Engineers, Teachers , Or The Occupation Of Similar Hazard. Persons engaged in Manual Labour , Garage Mechanic , Machine Operator, Paid Driver, Cash Carrying Employee, Builder, Contractor , Sportsmen , Sales - Executives, Or the Occupation of Similar Hazard. Persons engaged as workers in Underground Mine, Electric Installation with High Tension Supply, Jockeys, Circus Performers, Mountaineers , Skiing, Ice Hockey, River Rafting , Or The Occupation of Similar Hazard.
71
What to Consider while Selecting PA Policy?

• Opt For The Best Possible Coverage at Affordable
  Rates. Make Sure , Person is Not Under Covered.
• Along with Standard PA Cover , Many Insurers
  Offer Other Benefits Like Compensation For Loss
  Of Income, Loan Protection, Child Education
  Benefit , Cover For Medical Expenses , Cost of
  Ambulance Charges, etc. One Should Select Policy
  As Per Benefit Required.
• One Should Check Whether The Policy Provides
  Coverage Outside India.
• Before Purchasing PA Policy Always Check What
  Are The Accidental Events Covered Exclusions
  in The Policy Offerings.
• Check And Compare the Table of Compensation
  Offered As of Sum Assured For Particular
  Accident Such As Loss Of Hand, Leg, Toe ,
  Finger , Eye , Hearing Loss etc.

72
Claim Procedure in Personal Accident Insurance?

• CLAIMS INTIMATION
• In Case Of Any Accident , Intimation Must
  Be Given On Mail / Letter Or On The Toll
  Free Number Provided By The Insurer.
• Information Required for Claim Intimation
• Insured Name Contact details
• Policy No
• Date Time of Accident
• Nature , Place Description of Loss
• Hospital Name Address if admitted
• Name Add. Of Police Station If FIR filed
• Name of Person who took insured to Hospital
• Name of Doctor Treating the Patient
• Designation Grade of person in case of Group
  PA.
•  

CLAIM INTIMATION
73
Documents Required to Process Claim of Personal
Accident

• DOCUMENTS REQUIRED FOR
• DEATH CLAIMS
• Claim Form Duly Filled
• Attending Doctors Report
• Police Panchnama , FIR
• Post mortem Report
• Hospital Admission History if admitted
• Death Certificate
•  

74
Documents Required to Process Claim of Personal
Accident

• DOCUMENTS FOR
• PERMANENT TOTAL DISABILITY
• Claim Form Duly filled
• Attending Doctors Report
• Disability Certificate from Civil Surgeon
• All the investigation Reports / X-rays with Film
• Hospital Admission / Discharge Card
•  

75
Documents Required to Process Claim of Personal
Accident

• DOCUMENTS FOR
• TEMPORARY TOTAL DISABILITY
• Claim Form Duly filled
• Attending Doctors Report
• Medical Certificate from Civil Surgeon
• Leave Certificate from Employer in case of
  Salaried
• All the investigation Reports / X-rays with Film
• Hospital Admission / Discharge Card
•  

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