Download Swasthya Kavach

Swasthya Kavach
(Family Health) Policy
What is Swasthya Kavach?
The Policy offers a protection cover for you and your family for
any injury or disease related contingencies like hospitalization,
medical expenses, surgical expenses, Organ transplantation
etc.
The Policy covers the members of the Family consisting of
you, your spouse and dependent children up to the age of 23
years on a floater basis. Coverage is under a single Sum
Insured and no separate Sum Insured is required for each
member of the Family. Thus each member of Family draws
claim from the single Limit of Indemnity.
Unique Selling Proposition
– Critical illness gives you an option of differential pricing on differential
treatment-you can take a low basic Sum Insured for the general
ailments and the high critical illness sum insured protects you against
more expensive treatments.
– The critical Illness Cover is a indemnification cover and not a benefit
policy- Hence even after the critical illness is detected you continue to
get renewals .
– First Time critical Illness Family Floater cover in India
– When compared to IMI with the little more extra than one is required to
pay for his own cover, he can cover the entire family
– Emergency Assistance service (No competitor is offering this feature)
– It is one of the most inexpensive covers you can buy in the target
segment of below 45 years
WHO CAN OPT FOR SUCH COVERS?
Family
The fresh proposal up to the age of 55
shall only be accepted and can be renewed up to the age of 65
Premium chart based
Oldest Member
Maximum of three dependent children From 91 days and up to
the age of 23 can be covered
Parents are not covered. Proposal only for self or for
single member will not be accepted
Swasthya Kavach is offered under two Plans
Base Plan
Target Audience
Families who are located in
rural areas, small towns
Wider Plan
Middle class families located in metros who
are looking for Health care financing at
reasonable prices
Families who are looking for Health care
financing at reasonable prices
Families who would like to
cover the family against
unforeseen disease or
accident in an affordable Plan.
I) Basic Cover only
II) Basic Cover with
Critical Illness
Common Coverage under Base Plan and Wider Plan
(with varying limits of Coverage)
# Room and ICU Charges
# Pre-Hospitalization
including authorized
and Post Hospitalization expenses
home nursing
# Ambulance service expenses
# Daily Allowance for bearing miscellaneous expenses
for the duration of Hospitalization
Common Coverage under
Base Plan and Wider Plan
# Doctor’s fees, Cost of Medicines, Pathological Tests, etc.
# Pre-existing disease after 4 continuous Policy years with us.
# Prosthetic Devices like Pacemaker, Artificial Limbs etc.
# Transplants including Donor’s treatment and organs transplantation cost
# Dental surgery and treatment following an accident
# Defined Day Care Surgeries
# Vitamin and tonics consistent with illness
Common Exclusions under
Base Plan and Wider Plan
Naturopathy, use of Ayurvedic treatment experimental or alternative medicine,
procedure and treatment including acupressure, acupuncture, magnetic
treatment and such other therapies.
Any diseases or injuries related to hazardous sports like bungee jumping,
parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding or rock
climbing etc.
Any Genetic disorders.
External medical equipment of any kind used at home as Post Hospitalization
care, like wheelchairs, crutches etc.
Treatment of obesity or condition arising there from (including morbid obesity)
and any other weight control programe.
First 10% of any admissible claim if he is suffering from either Diabetes or
Hypertension and First 25% of the admissible claim amount in case he is
suffering from both diabetes and hypertension.
The above provision is applicable only for claims arising out of Diabetes and/or Hypertension.
Common Exclusions under
Base Plan and Wider Plan Contd..
 Diseases which are Pre-existing at inception of the first Policy.
 Diseases contracted during the first 30 days of Policy
 During the first year of the Policy, the expenses on treatment of diseases such as Tonsillitis/
Adenoids, Gastric or Duodenal Ulcer, Any type of Cyst/ Nodules/ Polyps, Any type of Breast
lumps.
 During the first two continuous years of the insurance with ITGI, the expenses on
treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy
for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis,
Choletithiasis and Cholecystectomy, Inter- vertebral Disc Prolapse (other than caused
by an accident), Osteoarthritis, Varicose Veins / Varicose Ulcers etc.
 Cosmetic or aesthetic treatment, general debility, use of intoxicating drugs, intentional self
injury.
 AIDS related expenses, venereal disease, congenital disease
Additional Exclusions under the Base Plan
•
During the first two continuous years of the Policy, the expenses on treatment of diseases
such as Renal Failure, Heart Diseases, any type of Carcinoma/Sarcoma/Blood Cancer.
Plans are differentiated by the limits in claims cost for individual
diseases, sub limits and exclusions applicable. These Differences
are as under :S.No Benefits
Base Plan
Wider Plan
1.
Cost of Health
Check up
Not Applicable
The reimbursement shall not
exceed the amount equal to
1% of the average Floater Sum
Insured during the block of four
claim free years of Insurance with
Us.
2.
Daily Allowance Rs 150 per day
Rs 250 per day
3.
Post –
Hospitalization
Relevant medical expenses
incurred up to 60 days
after Hospitalization on
Disease/illness/ Injury sustained,
which will be part of
Hospitalization expenses claim
Medical expenses up to
7% of Hospitalization
expenses incurred up
to max.30 days after
Hospitalization maximum
to Rs 7500
S.No Benefits
Base Plan
Wider Plan
4.
Restriction on other hospital
expenses in accordance with
the room rent.
Applicable
Not Applicable
5.
Ambulance charges
Rs. 750/-or actual whichever is
less
Rs. 1500/- or actual
whichever is less.
6.
Sub limit per day for Normal
Room expenses:
1.0% of the Sum Insured
1.5% Basic Sum
Insured
7.
Sub limit per day for Intensive 2.0% of the Sum Insured
Care Unit
2.5% of Basic Sum
Insured
8.
Additional Exclusions for first
two continuous years of
Policy
Covered
Chronic Renal failure or End
Stage Renal Failure.
Heart Disease.
Any type of Carcinoma /
Sarcoma/ Blood Cancer.
S.No
Benefits
9.
Add on
features:
10.
Base Plan
Wider Plan
Cumulative
Bonus
Not Applicable
Increased by 5% of the Basic Sum Insured at
each renewal in respect of each claim free
year of insurance, subject to maximum of 50%
of the Basic Sum Insured
Critical Illness
Not Applicable
Optional cover
Limit of
Liability
Basic Sum
Insured
under option I : Limit of Liability is the Sum
Insured + Cumulative Bonus if earned for
claim free year
under option II : the total Sum Insured of the
Basic Cover and Optional Extension +
Cumulative Bonus (if any) on Basic Sum
Insured
S.No
Benefits
Base Plan
Wider Plan
11
Specified List of treatments
have Expenses limit per
treatment per claim or actual
whichever is less for example
Cataract, Piles, Fistula,
Tonsillitis , Sinusitis, Hernia ,
Knee/ Hip Joint Replacement,
etc.
Applicable
Not Applicable
List of Treatments Under Base Plan
Treatment List
1) Cataract
Expense Limit per Claim
7.5% of the Sum Insured subject to
maximum of Rs. 15000/-
2) Piles, Fistula,
Fissure, Tonsillitis,
Sinusitis
10 % of the Sum Insured subject to
maximum of Rs. 30000/-
3) Benign Prostatic
Hypertrophy, Hernia
20% of the Sum Insured subject to
maximum of Rs.50000/-
4) Knee/ Hip Joint
Replacement, All Cancer,
Renal Failure
50% of the Sum Insured subject to
maximum of Rs 200000/-
5) Appendicitis, Gall
Bladder stones and
Hysterectomy
15% of the Sum Insured subject to
maximum of Rs 40000/-
Benefits available
Sum Insured options are Rs. 200000/-, Rs. 300000/- , Rs.400000/- and Rs. 500000/- for two,
three, four and five member family.
Policy is not portable which means that benefits enjoyed in other
policies of ITGI or policies with other insurer (other than similar floater cover)
are not transferable. ( Transfer Only to the Wider Plan)
Emergency Assistance Services are available with all the plan options and remains
the same in scope of cover as in IMI and IAH policy.
Third Party Administrator is RakshaTPA.
It has to be kept in mind that the above Emergency Services will be provided as
direct service to the Insured by Emergency Assistance Service Provider free of cost.
There will be no facility of any cash payment under these heads or reimbursement
of expenses incurred directly by the Insured or through any other service/ agency.
Emergency Assistance Services Provider
Medical Consultation, Evaluation and Referral
Emergency Medical Evacuation
Medical Repatriation
Transportation to Join Patient
Care and/or Transportation of Minor Children
Emergency Message Transmission
Return of Mortal Remains
Emergency Cash Coordination
Premium Table
The cover is provided under two Plans
1. Base Plan 2. Wider Plan
with two options viz.
Highest Age
a) Basic Cover
b) Basic Cover + Critical illness
Age limit: Proposer 18 years to 60 years
Children 91 days to 23 years
ITGI provides for the Policy with the premium based on Age, the Plan
and Family size as applicable from time to time. Dependent parents
are not covered.
Premium Table
Premium Table is provided with following options
1) Proposer + Spouse
2) Proposer+ Spouse + 1 child
3) Proposer + Spouse + 2 children
4) Proposer + Spouse + 3 children
5) Proposer + one child
6) Proposer + two children
7) Proposer + three children
Premium is provided without Service Tax and therefore needs to
be loaded accordingly.
Individual and self alone proposal with parents are not covered . The
parents can take separate proposal and cover themselves..
Premium comparison for Sum Insured of
Rs. 200000/- for a family of 2 adults + 2 children
36-45
12000
10000
8000
6000
4000
2000
0
Underwriting Process
The Policies shall be accepted and written by all the operating
offices up to the age of 45.The proposal with Pre-existing
disease and/or with the age of 45 years shall require approval
from Corporate office.
The premium is based on the highest age in the family,
the size of the family , the sum insured and the type of Plan
Raksha TPA shall be issuing the member cards and the Beneficiary
Guide, which will also carry the contact numbers of Emergency
Assistance Service Provider for availing the aforesaid special services.
Documents required for settlement of claims
 Claim Form
 Discharge Summary, Bills and Receipt of Hospital/Nursing,
Home Attending Doctor’s Report and Bills as well as cash
memos of medicines and pathological tests duly supported by
proper prescription.
 F.I.R, Post Mortem Report, Final Investigation Report etc.
in case of an accident.
Claim Process
The claims process for the cashless claim settlement shall remain
the same as at present under IMI Policies but for the change in TPA.
Emergency Assistance Service Provider shall only respond to
emergency situations out side the home town of the insured person
(during travel beyond 150 kms. within India) and the TPA takes
over from the time the insured person is actually admitted as an
inpatient in a hospital.
Dedicated center of RakshaTPA at Faridabad shall act as the centralized
processing unit for all claims under this Policy whether on Cashless or
Reimbursement basis or for claims under Personal Accident Benefit. This
exclusive center will be in constant coordination with AAMESIL and our
Health Claims Unit at CCU to ensure that best possible service level are
maintained.
Thank You