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Step 1 – the policyholder chooses the Sum Assured, the term of the plan, members to be covered and the plan variant.
Step 2 – the policyholder might also choose optional co-pay feature.
Step 3 – premium is calculated based on the Sum Insured, term, plan variant, members covered and the location of the insured.
Step 4 – If the insured faces any medical contingency and the related expenses are covered by the plan the expenses incurred are paid by the plan.
Step 5 – if the plan matures and no medical contingencies occur, no benefit is paid. However, the Sum Insured increases due to cumulative bonus feature.
Rahim buys the policy covering him, his wife and 2 kids. The Sum Insured he chooses is Rs.10 lakhs and the tenure is 2 years.
Option 1 – Rahim’s wife suffers a fracture for which she is hospitalized. The bill comes to Rs.2 lakhs which is paid by the plan.
Option 2 – The first year of the plan comes to an end but Rahim does not make any claim. He gets a cumulative bonus of 10% increase in Sum Insured which becomes Rs.11 lakhs.
Sum Insured Rs.1.5 or 2 lakhs
Sum Insured Rs.3-50 lakhs
|Room rent||1% of Sum Insured/day||No sub-limits|
|Day care treatments||Covered||Covered|
|Pre-hospitalization||60 days||60 days|
|Post hospitalization||90 days||90 days|
|Organ Donor expenses||Covered||Covered|
|AYUSH treatments||Not covered||Up to Rs.20,000|
|Maternity Expenses||Not covered||Sum Insured Rs.3-7.5 lakhs
Normal delivery – Rs.15,000
Cesarean delivery – Rs.25,000
Sum Insured Rs.10 lakhs and above
Normal delivery– Rs.25,000
Cesarean delivery – Rs.35,000
|New born baby cover||Not covered||Up to maternity Sum Insured for 90 days|
|Vaccination for newborn baby||Not covered||Up to maternity Sum Insured for 90 days|
|Bariatric surgery||Not covered||50% of Sum Insured up to Rs.5 lakhs|
|Daily Cash Benefit for accompanying minor child (for plans with a term >1 year)||Rs.500/day up to Rs.5000||Rs.500/day up to Rs.5000|
|Convalescence benefit (for plans with a term >1 year)||Rs.5000 if hospitalization exceeds 10 days||Rs.5000 for Sum Insured up to Rs.5 lakhs and Rs.7500 for Sum Insured Rs.7.5 lakhs and above if hospitalization exceeds 10 days|
|AYUSH Coverage||Up to Rs.20,000||Up to Rs.20,000|
|Ambulance cover||Up to Rs.20,000||Up to Rs.20,000|
|Health check-ups||Up to 1% of Sum once every 3 years to a maximum of Rs.2000||Up to 1% of Sum once every 3 years to a maximum of Rs.5000|
|Sum Insured reinstatement (for plans with a term >1 year)||Up to 100% of the original Sum Insured||Up to 100% of the original Sum Insured|
|Age at entry (in completed years)||Adults - 18 years
Dependent children – 3 months
|Adults - 65 years
Dependent children – 30 years
|Plan tenure||1 year||3 years|
|Premium paying options||Single pay|
|Sum Assured||Rs.1.5 lakhs||Rs.15 lakhs|
Illnesses suffered during the first 30 days of the plan commencement are not covered.
Critical Illnesses suffered during the first 90 days of the plan commencement are not covered.
Pre-existing illnesses or conditions are not covered by the plan in the first 3 years of the policy
Maternity related expenses have a waiting period of 75 months
Bariatric surgery is covered after the first 3 years of the policy
Specific illnesses are not covered in the first two years of the plan.
Illnesses or accidents caused due to genetic disorder or stem cell surgery, substance abuse, participation in adventure sports or hazardous activities, criminal acts, attempted suicide, war and hazardous substances, etc. are not covered.
Treatments like cosmetic treatments, artificial life support, weight loss treatments, non-allopathic treatments or due to HIV/AIDS, etc. are not covered.
Below are the sample rates of premium payable by a non-smoking male aged 40 years living in Delhi for different combinations of plan variants and members covered. The Sum Insured is Rs.2 lakhs for Silver Plan and Rs.5 lakhs for Gold Plan and the policy is taken for 1 year.