Step 1 – the policyholder chooses the Sum Assured, the term of the plan 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 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 4 – if the plan matures and no medical contingencies occur, no benefit is paid.
Vinit buys the Health Guard Individual Plan for a Sum Insured of Rs.5 lakhs. He chooses the gold variant for a term of 2 years.
Option 1 – Vinit undergoes treatment for Bariatric Surgery after 3 years of plan commencement. He is paid Rs.2.5 lakhs as claim.
Option 2 – Vinit is hospitalized for an accident, his medical bills are paid by the plan up to the chosen Sum Insured.
Option 3 – The first year of the plan comes to an end but Vinit does not make any claim. He gets a cumulative bonus of 10% increase in Sum Insured which becomes Rs.5.5 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)||18 years||65 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 for different combinations of age, plan variants and geographical zones. 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.
Daily cash benefit for accompanying child is payable only if the child in question is a minor child aged below 12 years. Moreover, this cover is available if the tenure is more than one year.
The reinstatement benefit is paid for claims pertaining to cancer of specified severity and for kidney failure which requires regular dialysis.
Maternity expenses are paid according to the sub-limits for a maximum of 2 deliveries.
Bariatric surgery benefits are paid for adults above 18 years of age if BMI is greater than or equal to 40 and the insured suffers from one of the following conditions:
The limit is 20% of the Sum Insured up to a maximum of Rs.1 lakh in both variants.