2 Hospitalization Expenses incurred as an inpatient for CoveragesHospitalization Expenses incurred as an inpatient forSickness/Illness/DiseasesAccidental injuriesIn-Patient means an Insured Person who is admitted to hospital and stays there for a minimum period of 24 hours for the sole purpose of receiving treatment.
3 What is a Hospital?Hospital, Nursing Home means any institution in India established for indoor care and treatment of sickness and injuries and whichEitherIt has been registered with the local authorities and is under the supervision of a registered and qualified Medical PractitionerorShould comply with minimum criteria as underIt 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 clockFully qualified Doctor(s) should be in charge round the clock.Hospital / Nursing Home means any institution in India established for indoor care and treatment of sickness and injuries and which EITHER has been registered either as hospital or nursing home with the local auhorities and is under the supervision of a registered and qualified Medical Practitioner,fully qualified nursing staff under the employment and fully qualified doctor should be in charge round the clock
4 Age Limits 5 Months – 59 Yrs (age last Birthday) Dependent Children can be covered only with any one of their Parents.Single person in the family will not be covered-unless ALL other family members are covered with Star Health .Renewable up to 80 yrs
5 Medical Examination For persons with adverse medical history and For all persons above 51 yearsAll Sum Insuredacceptance subject to Medical Examination at Company’s Cost.* The Procedure for Acceptance of MedicalProposals
6 Pre Medical Exam TMT required : Age is above 51 years – S.I. of Rs.10 lacs and aboveBMI = Weight in Kgs. (Height in meter)2More than 35 BMI – NOT Accepted
7 Declined Risks: Heart Brain Chronic Kidney Problems, Paralysis Diabetes- ( Type- I)AlzheimerParkinsonCancer problemsPolio at the inception (in the lifetime)
8 Documentation: Non Medical Proposals: Medical Proposals: Proposal Form-Completely FilledONE PhotographFor all proposals from persons above 45 years, age proof in the form of School Certificate/Pan Card/Driving License/Passport/Ration Card is required.Medical Proposals:TWO Photographs- only for those who require to undergo medical tests
9 Allowable ExpensesRoom rent & boarding 2% of the sum insured up-to a maximum of Rs. 5,000/- per dayRoom rent & boarding 2% of the sum insured up-to a maximum of Rs. 4,000/- per day
11 Allowable Expenses Surgeons, Anesthetist, Consultants and Specialists feesOperation Theatre charges,drugs and medicines,diagnostic materials,cost of pace maker etc
12 Allowable ExpensesEmergency Ambulance charges to go to Hospital for Rs 750/- per hospitalisation upto a maximum of Rs 1,500/- per policy period
13 Allowable Expenses (Contd.) Pre-Hospitalization expenses incurred for a period of30 days prior to the dateof hospitalization
14 Allowable Expenses (Contd.) Post Hospitalization expensesOn a lump-sum 7% ofHospitalization expenses incurredComprising of Nursing Charges,Surgeon/Consultant fees, DiagnosticCharges, Medicines and Drugs onlySubject to a maximum of Rs 5,000/- perOccurrence.
15 Allowable Expenses (Contd.) Reasonable & Customary Charges:Means a charge which:is charged for medical treatment, supplies or medical services that are necessary to treat Your conditionDoes not exceed the usual level of charges for similar medical treatment, supplies or medical services in the locality where the expenses is incurred andDoes not include charges that would not have been made if no insurance existed.
16 Day Care TreatmentMinimum of 24 hours Hospitalization is not necessary for the followingDialysis,Chemotherapy,Radiotherapy,Cataract surgery,Dental Surgery,Lithotripsy (Kidney stone removal),Tonsillectomy,Cutting and Draining of Abscess,Liver Aspiration,Pleural Effusion Aspiration,Colonoscopy,Sclerotheraphy,The above treatment shall be taken in the Hospital / Nursing Home and the Insured is discharged on the same day.
17 Name of the Ailment / Surgery / Procedure Sub limitsName of the Ailment / Surgery / ProcedureSub LimitCataract surgeryRs. 20,000/- in respect of one eye andRs. 30,000/- in the entire policy periodLithotripsy (Kidney stone removal)Rs. 20,000/-TonsillectomyRs. 7,500/-Cutting and Draining of AbscessRs. 1,500/-Liver AspirationRs. 2,000/-Pleural Effusion AspirationColonoscopySclerotheraphyRs. 5,000/-
18 No Claim Discounts (NCD) in case of Renewal 5% Discount on Basic Premium for every Claim Free YearMaximum 25%In the event of a ClaimOne Step back in NCD for Age Group 5M – 35 YrsTwo Steps back for Age Group 36 – 45 YrsAbove 45 Yrs – No NCD
19 Portability w.e.f. 1st Oct.2011All proposals must be referred to Portability CellPlease note that the filled up proposal form and other details will have to be received at least 30 days in advance from the due date for renewal of the existing policy.Documents Required –i) Duly completed & signed proposal form with passport size photograph.ii) Portability form for all members of family (part I & II)iii) Age proof (wherever applicable)iv) Copies of existing policy and earlier policies.Please note that,PREMIUM SHALL NOT BE COLLECTED AT THIS POINT OF TIME. i.e No cheque or cash or payment by any other mode shall be collected till the final decision for acceptance or rejection is made by the Portability cell.Pre medical will be done at co. cost and then it will be referred to Corp. off.The matter will be taken up with IRDA portal by the Portability cell and after getting the necessary details from the IRDA portal, decision will be taken at the corporate office whether to accept or reject the application for portability.
20 Other Benefits Benefits under Section 80-D of the IT Act Cashless Service without involvement of TPADirect Tie up with hospitals on an All India Basis24 X 7 In-House Call center ( )Toll Free Telephone line assistance( / )Full knowledge based website to offer medical information, including Health Tips.
21 Optional BenefitsThe following Optional benefits can be availed on payment of Additional PremiumHospital Cash :This insurance provides for Cash benefit of Rs. 500/- for and each and every completed day of Hospitalisation subject to a maximum of Rs. 1,500/- per hospitalisation and Rs. 3,000/- per policy period.Insured persons aged less than 21 years and more than 60 years are not entitled for this benefit.PremiumAge BandPremium (Rs.)0-35 Years20036-45 Years25046-55 Years30056-60 Years350
22 Exclusions Any Disease contracted during first 30 days Pre-existing Diseases( for first 4 yrs. with Star Health without Break )Any Disease contracted during first 30 daysFirst Year ExclusionsBenign prostate hypertrophyHernia, Hydrocele, Fistula in Anus, PilesSinusitiscongenital internal disease/defectRenal stone and Gall stone removalFirst Two Years ExclusionsCataracthysterectomy following menorrhea or fibromyomaKnee Replacement Surgery ( unless caused by accident )Joint Replacement Surgery ( unless caused by accident )Prolapse of intervertibral DiscVaricose veins / Ulcers
23 Exclusions (Contd.)Injury / Disease arising due to War, Invasion, Act of Foreign Enemy, Warlike operationsCost of spectacles and contact lens, hearing aids, walkers, crutches wheel chairs and such other aidsDental treatment or surgeryConvalescence, 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/alcoholNaturopathy TreatmentExpenses incurred on Lasik Laser or Refractive Error Correction treatment
24 Exclusions (Contd.)Hospital registration charges, record charges, telephone charges and such other similar charges.Non Allopathic shall be restricted to 25% of the sum insured subject to a maximum of Rs. 25,000/- for the entire policy period.
25 In case of Network Hospitals Claim ProcedureIn case of Network HospitalsImmediate intimation to the Call Centre( / / )The insured has to send a request for ‘Pre Authorization Form’ signed by the Doctor in the Network HospitalBased on the intimation a field visit will be done by the Star DoctorPre Authorization will be issued to the HospitalBased on the Pre Authorization and the Report by the Star Doctor, Cash Less Treatment will be given by the Network HospitalNote: Late Intimation / No Intimation of the claim will not be entertained
26 In case of Non Network Hospitals - Claim Procedure Immediate intimation to the Call Centre( / / )Claim form will be sent to the Insured.Based on the intimation a field visit will be done by the Star DoctorBills has to be settled by the Insured and will be reimbursed by Star on submitting the following documentsOriginal Discharge SummaryMain Hospital Bill with Break UpInvestigation Reports with X-Ray FilmMedical Bills with PrescriptionsIPD PAPERS ( Indoor Patient )Note:Late Intimation of the claim will not be entertained.Claim file / Documents need to be submitted within 15 days
27 Discuss Agents Role ( Renewal, Service, Premium collection, training, utmost good faith, Disclosure of material facts)Cashless is Direct settlement – Not without cashAdmission in network Hospitals ONLYRewards : Blackberry July-Aug-Sept’11, LCD TV, Foreign Trip etc.Group Insurance
28 FAQ: Medi-Classic 1. Which policy is suitable for an individual? Ans - Medi-classic policy is suitable for an individual. It provides cover on an Individual basis.2. What is the entry age for Medi-classic?Ans: The minimum entry age for Medi-classic is minimum 5months and maximum 60 yrs.3. Which type of hospitalization is covered under this policy?Ans – Medi-classic covers hospitalization due to sickness, illness or diseases and due to accident.
29 FAQ: Medi-Classic4. What is the minimum required period of hospitalization?Ans - The minimum required period of hospitalization is at least 24 hours. This rule has some exceptions which are called day care treatments.5. What is meant by day care treatments?Ans – The day care treatment means the treatment which does require 24 hours hospitalization. Following are the Day care treatments, which are covered currently- Dialysis, Chemotherapy, Radiotherapy, Cataract surgery, Dental Surgery(Only due to Accident), Lithotripsy (Kidney stone removal),Tonsillectomy, Cutting and Draining of Abscess, Liver Aspiration, Pleural Effusion Aspiration, Colonoscopy, Sclerotheraphy.
30 FAQ: Medi-Classic6. What are the options provided for Sum Insured, in Medi-classic?Ans- In Medi-classic the minimum Sum Insured can be offered is of Rs.1 Lakh, maximum upto Rs.10 Lakhs.7. What is NO Claim Discount? How much is it?Ans - In Medi-classic policy, Star Health gives discount on basic premium, for each claim free year, at the time renewal of the policy. The No Claim discount ranges from 5% to 25%.8. What is hospital Cash Benefit?Ans - This is an optional benefit, provided in Medi-Classic on payment of additional premium. It provides cash benefit of Rs. 500/- for and each and every completed day of Hospitalisation subject to a maximum of Rs. 1,500/- per hospitalisation and Rs. 3,000/- per policy period. This optional benefit is available to the persons who are between 21 to 60 yrs
31 FAQ: Medi-Classic8. Is there any waiting period for the commencement of the cover?Ans –There is a waiting period of 30 days from the date of issuance of the policy A waiting period is the length of time the insured may have to wait before being eligible for Health Policy benefits. It is applicable only for the first policy period with Star Health.9. Which diseases are not covered in the first year, only?Ans - Following diseases are not coverd for the first year only- Benign prostate hypertrophy,Hernia, Hydrocele, Fistula in Anus, Piles,Sinusitis,congenital internal disease/defect,Renal stone and Gall stone removal
32 FAQ: Medi-Classic10. Which diseases are not covered for the first two years, only?Ans – Following diseases are not coverd for the first two years- Cataract,hysterectomy following menorrhea or fibromyoma,Knee Replacement Surgery ( unless caused by accident ),Joint Replacement Surgery ( unless caused by accident ),Prolapse of intervertibral Disc,Varicose veins / Ulcers.11. What if a person is already suffering from any disease/s?Ans - If a person is already suffering from any of the diseases, that disease/s(Pre-Existing Disease/s) will be covered only after the four years with Star health without any break.12. Is any Naturopathy treatment covered under Medi-Classic?Ans – Naturopathy treatments are not covered under Medi-Classic / any other policy of Star Health
33 FAQ: Medi-Classic13. Is any kind of Dental Treament covered under Medi-classic?Ans - Dental Treament is covered under Medi-classic / any other health policy but only if it is due to Accident.14. Do you cover Non Allopathic Treatments in Medi-Classic?Ans – Non Allopathic Treatments are covered under Medi-classic policy. There should be hospitalization of at least 24 hrs. They are covered up-to 25% of Sum Insured or Rs.25000/- or actual expenses whichever is less.
34 FAQ: Medi-Classic 15. What is the claim procedure? Ans – First, You need to inform the 24-hour Toll Free no / for assistance. One has to Inform the ID number / policy number for easy reference.In case of planned hospitalization, please inform 24 hours prior to admission into the hospital.In case of hospitalization due to emergency, information must be given within 24 hours after hospitalization.In case of non-network hospitals, payment must be made upfront by the policy holder and then reimbursement will be effected on the submission of documents.Intimation on the Toll free Number is a must.
35 FAQ: Medi-Classic16. Why should I take a Health Plan if I already have health insurance from my employer?Ans - Your employer will cover your medical expenses only as long as you are in his services. Tomorrow, you may change your job, retire, or even start something on your own. In all such cases you and your family will be stranded if a medical emergency arises and you have not arranged for an alternative health insurance policy. It is at this point of time that Health Insurance policy will come to your rescue. Health Insurance policy can also act as a supplement to your existing medical cover in case the cost of medical treatment is higher than your existing cover level.
36 True or FalseMini and Max S.I. in Medi Classic is Rs one Lakh and 15 Lakh.Med classic can be renewed for life long with some loading.Hospital cash benefit is available up to max Rs 1500 per hospitalization.Max cash benefit Rs 6000 per policy period for persons above 60 years.No claim discount (NCD)is available from 5 to 25% cumulatively.Once cash benefit opted No claim discount (NCD)is not available.Covers starts immediately once policy is in force.For PED cover is available only after 4 years.For Non Allopathic treatment cover is available up to 25% of basic S.I.