Health Insurance

Bharti

AXA Smart Health Insurance Policy

Agenda

Product
Need for Health Insurance Smart Health Insurance Basic Covers

Guidelines & Processes

Underwriting Guidelines Claims Process Important Guidelines

Value-added Benefits
Additional Features Exclusions Plan and Premium

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Does this sound familiar?

Need for Health Insurance

You pay a visit to the doctor..

You buy the medicines the doctor prescribed

You are still unwellso you get hospitalised

You undergo medical tests

You get hospitalised for a surgery

You take some medicines for faster recovery..

All these involve a lot of money

You suddenly feel unwell

You are well again

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And the result.

You might feel like doing this.

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Multi-dimensional Impact
Potential Loss of income Familys Health Hospitalisation expenses

Depleted savings

Ad-hoc expenses

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What are the expenses related to hospitalisation?

Before Hospitalisation During Hospitalisation Post Hospitalisation

Doctor fees Cost of medicines Cost towards medical tests

Room Charges Operation Theater Charges Surgery/Operation/ Treatment Costs Cost of medicines. Blood, oxygen etc Doctor/Specialist/ Surgeon fees Nursing Charges

Doctor fees Cost of medicines Cost towards medical tests

Covered under basic covers

Associated Costs:
Loss of income Expenses towards food of accompanying persons/visitors Transport expenses for accompanying persons/visitors Ambulance charges etc
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Covered as value-added benefits

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Smart Health for Smart People

Your Smart Health Insurance Policy provides complete financial protection for you and your family against Hospitalization Expenses

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Coverage

The Smart Health Insurance Policy covers: Hospitalisation Benefit Domiciliary Hospitalisation Day Care Treatment Pre and Post Hospitalisation Expenses Critical Illness - Dread Disease Recuperation - Transplantation of Organs

Please refer the plan details for the Sum Insured options with respect to these benefits For more dtails please visit at www.bharti-axagi.co.in or call us at 080-49010200

Hospitalisation Benefit

Covers expenses incurred by Insured Person as an in-patient in a hospital In relation to treatment of disease or injury. This includes: Hospital (Room & Boarding and Operation theatre) charges Fees of Surgeon, Anesthetist, Nurses, Specialists Cost of diagnostic tests, medicines, blood, oxygen Cost of appliances like pacemaker, artificial limbs and organs This is applicable only if the period of hospitalisation exceeds 24 hours.

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Domiciliary Hospitalisation

Reimbursement of expenses involving medical treatment for disease/injury at the Insured Persons home in India The treatment would have in normal course, done in a hospital/nursing home, but is taking place at Insured Persons home only because i. the condition of the patient is such that he / she cannot be moved to Hospital / Nursing Home, or ii. the patient cannot be admitted to Hospital/Nursing Home for lack of accommodation therein. This is applicable only if the treatment is done at home for a period exceeding 3 days

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Day Care Treatment

Payment or reimbursement of hospitalisation expenses incurred in case of treatment, where 24 hours of hospitalisation is not required due to technologically advanced treatment protocol This includes:

Dialysis - Kidney Chemotherapy - Cancer Radiotherapy - Cancer Eye surgery - Eye Dental surgery - Dental Lithotripsy (Kidney stone removal) Tonsillectomy - Tonsils Dilatation & Curettage

Cardiac Catheterization Hydrocele surgery Hernia repair surgery TURP (Prostate Surgery) Surgeries/procedures that require less than 24 hours hospitalisation due to medical/technological advancement and infrastructural facilities.

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Pre and post hospitalisation expenses

Pre-hospitalisation Expenses Post Hospitalisation Expenses Payment or reimbursement of Payment or reimbursement of expenses incurred for specified expenses incurred for days post discharge from Hospital specified days prior to hospitalisation
Optimum Optimum

60 days

Hospitalisation

90 days

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Critical Illness

Covers expenses incurred for treatment of any of the specified critical illnesses Coverage is available in either of the following options:
Payment of lump sum benefit amount if the Insured Person is being

diagnosed as contracting any of specified Critical Illnesses and surviving for more than 30 days post such diagnosis. Payment /reimbursement of expenses incurred for treatment of such specified Critical Illness in a Hospital / Nursing Home

This benefit is available after a waiting period of 60 days from the date of inception of the first year Policy The SI available under this benefit is separate and additional to the SI available under the Hospitalisation benefit Section of the Policy.

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Critical Illnesses
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Cancer First Heart Attack - Heart Coronary Artery Disease Heart Coronary Artery Bypass surgery - Heart Heart Valve Surgery - Heart Surgery to Aorta Heart Stroke - Brain Kidney Failure Aplastic Anaemia - Blood End Stage Lung Disease
First product in India to cover 20 critical illnesses

11. 12. 13. 14. 15. 16. 17. 18. 19.

20.

End Stage Liver Failure Coma - Brain Major Burns - Burns Major Organ/Bone Marrow Transplantation - Bone Multiple Sclerosis - Cancer Fulminant Hepatitis - Liver Motor Neurone Disease - Brain Primary Pulmonary Hypertension - Heart Terminal Illness Last stage of any illness Bacterial Meningitis - Brain

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SmartHealth Value Added Benefits Smart Health Benefits Out-patient Dental Emergency Hospital Cash Allowance

Home Nursing Treatment (arising out of Accident only) The SmartHealth Insurance Policy Out-patient Emergency treatment for Ambulance Charges also offers these benefits: In-patient Physiotherapy Charges accidents Hospital Cash Allowance Recovery Grant Home Nursing Children Education Fund Ambulance Charges Accompanying Persons Expenses Mortal Remains In-patient Physiotherapy Charges Parent Accommodation as Recovery Grant Accompanying Persons Expenses Companion for Child Parent Accommodation as Companion for Child

Out-patient Dental Emergency Treatment (arising out of Accident only) Out-patient Emergency treatment for accidents Children Education Fund Mortal Remains

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Please refer the plan details for the applicability and Sum Insured options with respect to these benefits For more dtails please visit at www.bharti-axagi.co.in or call us at 080-49010200

Hospital Cash Allowance

Payment of a daily hospitalisation expenses up to the applicable limits

In case the Insured is hospitalized for treatment of any disease/injury / critical

illness for which a valid claim is admissible under the Policy and if the hospitalisation exceeds the applicable number of days

This benefit is applicable irrespective of the number of occurrences during the Policy period subject to overall Sum Insured.

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Home Nursing

Payment of an allowance for medical care services of a nurse at the residence of the Insured following discharge from Hospital after a treatment for a disease / illness / injury / critical illness for which a valid claim under this Policy is admissible provided such medical care services are confirmed as being necessary by the attending Medical Practitioner and the treatment relates directly to the disease/ injury / critical illness for which the Insured has undertaken treatment during the hospitalisation, This benefit is applicable irrespective of the number of occurrences during the Policy period subject to the overall Sum Insured.

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Ambulance Charges

Reimbursement of expenses incurred for the transportation of the Insured Person by ambulance to and from the Hospital for treatment of disease, illness or injury in a Hospital as an inpatient for which a valid claim under this Policy is admissible. This benefit is applicable irrespective of the number of occurrences during the Policy period and is subject to the applicable limits.

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In-patient Physiotherapy Charges

Reimbursement of charges incurred towards physiotherapy in the Hospital as an in-patient that is confirmed as being necessary by the attending Medical Practitioner and the same relates directly to the disease, illness or injury for which the Insured Person has undertaken treatment in the Hospital for which a valid claim is admissible under this Policy. This benefit is applicable irrespective of the number of occurrences during the Policy period and is subject to the applicable limits.

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Recovery Grant

Payment of a fixed allowance/grant in case the Insured Person is hospitalized for a period of 8 consecutive days or more for treatment of any disease/injury for which a valid claim is admissible under the Policy This benefit is available upto the applicable limits under the Optimum Plan

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Accompanying Persons Expenses

Payment an allowance towards expenses incurred on the accompanying person at the Hospital during hospitalisation treatment of the Insured Person for the disease, illness or injury for which a valid claim is admissible under the Policy. This benefit is applicable irrespective of the number of occurrences during the Policy period and is subject to the applicable limits

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Parent Accommodation as Companion for Child

Payment of a fixed daily allowance towards meeting the expenses for the stay of one of the parents at the Hospital when a child below the age of 12 years is hospitalized. This benefit is applicable irrespective of the number of occurrences during the Policy period and is subject to the applicable limits.

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Out-patient Dental Emergency Treatment (arising out of Accident only)

Reimbursement of medical expenses incurred towards emergency treatment by a Dentist

following an accident where the Insured Person suffers injuries or damage to

his natural teeth and/or gums.

This benefit further provides cover for medical expenses incurred for follow up treatment for the same accidental dental injury up to a maximum of 15 days by the same Dentist.

This benefit is applicable irrespective of the number of occurrences during the Policy period and is subject to the applicable limits.

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Out-patient Emergency treatment for accidents

Reimbursement of medical expenses incurred towards emergency treatment by a Medical Practitioner following an accidental injury to the Insured Person and such Emergency Treatment administered within 24 hours following the accident. It also provides cover for medical expenses incurred for follow-up treatment by the same Medical Practitioner in respect of the same accidental injury up to 30 days from the date of accident. This including expenses incurred for medication prescribed on a written basis by the attending Medical Practitioner for that same treatment or consultation. This benefit is applicable irrespective of the number of occurrences during the Policy period and is subject to the applicable limits

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Children Education Fund

Payment of a fixed amount per dependent child in the event of death of the Insured Person whilst under treatment in a Hospital as an in-patient for a disease/injury and/or critical illness for which a valid claim is payable under the Policy. This is available for a maximum of two dependant children who pursue studies and are below the age of 23 years

The benefit is subject to the applicable limits as per the plan chosen.

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Mortal Remains

Reimbursement of expenses incurred for transportation of the mortal remains of the deceased Insured Person from Hospital to his/her place of residence in the event of death at the Hospital as an in-patient whilst under treatment of a disease / illness / injury and/or critical illness for which a valid claim is payable under the Policy This benefit is subject to the applicable limits as per the plan chosen.

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Additional Features Additional Features

Family Floater Feature Renewal Discount Income Tax Benefit Cost of Medical Check-up

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Family Floater
Policy can be issued on a Floater basis covering the family members of the Insured comprising the Insured, spouse and two dependant children (upto the age limit of 23 years).

What is floater, how does it benefit?

All members of the family (Self, Spouse, 2 Kids) can be covered under one single policy Single premium payable for the entire family

The amount of Sum Insured floats over the entire family

No need to insure individual members separately No hassles of tracking renewals for different members

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Renewal Discount

Discount equivalent to 5% of renewal premium every year on a progressive scale will be given back to the Insured as Renewal Discount at the time of renewal, This is applicable where the Policy which is renewed is claim free in the expiring year. This renewal discount on a progressive scale will be allowed upto a maxumum of 25%. In case of renewal of a Policy where there is a loss, the Insured will lose the entire Renewal Discount accumulated.

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Income Tax Benefit

Premium paid under the Policy shall be eligible for income tax deduction benefit under Sec 80 D as per the Income tax Act.

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Cost of Medical Check-up

Reimbursement of cost of medical check-up once at the end of a block of every four continuous underwriting years provided there were no claims reported /made under the Policy during the block. This benefit is limited to 1% of the average Sum Insured per person during the block of four underwriting years. This additional benefit is available on the policies taken and renewed with our Company for four continuous years without any claim.

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Major Exclusions
No payment will be made for any pre-existing disease or condition until 48 months of continuous coverage have elapsed, since inception of the first policy Any benefit under Critical Illness section within the first 60 days of policy inception Hospitalisation expenses incurred for treatment within 30 days of the inception date of this Policy Claims related to pregnancy, childbirth, fertility treatment etc Routine medical, eye/ear examinations, vitamins, tonics, cost of spectacles, lenses, hearing aids etc Cosmetic or Plastic Surgery unless necessitated by accidents War, nuclear perils, radiation etc use of intoxicating drugs and alcohol or drug abuse etc

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Claims Procedure

Claims can be either on: Cashless Basis Reimbursement Basis Claims to be adminstered by Third Party Administrators(TPA) Claims to be handled by the following TPAs as per the occurrence of the claim: Location of Hospital: South & West Zone Paramount Health Services Pvt Ltd Location of Hospital: North & East Zone Emeditek Solutions Ltd

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How to avail cashless service

Step1 : For planned hospitalization, forward your request letter 3-4 days prior to hospitalization in the prescribed format(format available from the website of the TPA/Insurance company, benefit guide, branch offices of TPA/Insurance company) For emergency hospitalization, forward your request letter within 24 hours of hospitalization in the prescribed format(format available from the website of the TPA/Insurance company, benefit guide, branch offices of TPA/Insurance company) Step 2 : TPA will issue an authorization letter for the coverage as per the policy to network hospital Step 3 : Insured approaches the network hospital with ID card and authorization letter Step 4: Network Hospital will extend cashless treatment to the insured up to authorized amount Step 5 : At the time of discharge insured leaves back all the documents and sign the claim form Step 7 : The Insured makes the payment in cash to network hospital for the services that are not covered under the policy

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How to avail reimbursment facility

Step1 : Incase of hospitalization in non network hospital, the insured is required to intimate the TPA 3-4 days prior to planned hospitalization and within 24 hours of emergency hospitalization Step 2 : Insured avails treatment from hospital and makes payment for the entire amount Step 3 : After discharge, the insured submits the necessary documents to the TPA within 7 days. Step 4: The Company to process the claim once all documents are submitted

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Indicative List of Documents

First prescription regarding the current illness for which treatment undergone in hospital/nursing home, in original Medical advice for hospitalization Discharge Summary of Hospital, in original Medical Fitness certificate, in original All test reports supported by medical prescription(pre & post hospitalization), in original All vouchers of the test report mentioned above, in original All medicines purchased from outside the hospital at any point of time to be supported by original prescription, in original Complete and signed claim form with filled in attending doctors prescription. Copy of the policy document

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Presentation title For more dtails

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Necessary Documentation
Important Guidelines

Completed proposal form in all respects and duly signed by the proposer All details written in proposal should be clear, do not leave any blanks or use any signs - Necessary test reports shall be submitted in full Premium in case of referral risks shall not be accepted without prior approval of the underwriting team Special condition/warranty if any incorporated by underwriting team shall be clearly mentioned in the policy schedule

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To summarize

One-stop solution to protect the health of the family members Covers hospitalization expenses for treatment of diseases or injuries Provides a host of value-added benefits such as Recovery Grant, Dread Disease Recuperation, Separate additional Sum Insured automatically available in case of diagnosis of any of the covered critical illnesse Three different plan variants - each with five different Sum Insured options to choose from Instant, Hassle Free Policy Delivery for customers aged 45 years or below. 24 hour cashless treatment facility available at more than 4000 of our network hospitals

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Plan Options

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Thank you

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