There was chaos in the Grover household. The family was in a tizzy as there was the last minute running around, before their trip. To add to the confusion, an insurance agent had come in regarding a medical policy and was asking them for photos, information etc. Amit Grover just about completed it and embarked on his trip.
On coming back, he was assailed with doubts as to whether he has done the right thing by taking Maxima from Apollo DKV. I explained to him that this is a medical insurance product which covers OPD, Dental, Optical, Maternity and other expenses, apart from hospitalisation. Also, critical illness can be taken on, optionally. I explained it to him in detail.
Policy Highlights :
• A medical insurance product that covers both hospitalization & outpatient treatments.
• Cashless claims in over 4000 network hospitals
• Inpatient treatment expenses due to hospitalization, including pre & post hospitalization expenses
• Outpatient treatments cover consultations with a doctor, diagnostic tests & medicines as prescribed by a doctor.
• 140 Daycare procedures and domiciliary hospitalization is covered.
• Medical expenses of organ donor is also covered.
• Emergency Ambulance, Maternity expenses coverage, option for covering newborn & daily hospital cash are other benefits.
• Dental treatment ( upto limits prescribed ) from a network dentist.
• Spectacles / Contact lenses if prescribed by network eye specialist ( upto specified limits ).
• Annual health checkup for the insured ( as per their terms )
• Rs.3 Lakhs is the only Sum Assured available under this plan
• This product can be taken for an individual or for a family of upto two children ( as a floater ). It can include dependant parents too, though maximum number that can be covered in a policy is four individuals.
Features & Benefits :
Inpatient Module -
Hospitalisation expenses - As a medical Insurance policy, it covers all hospitalisation expenses due to an illness or accident. The policy will pay for the expenses like Room rent, boarding expenses, Nursing, Intensive care unit, Medical Practitioner(s), Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines, drugs and consumables, Diagnostic procedures, Cost of prosthetic & other devices or equipments if implanted internally during a Surgical Procedure.
Pre & post hospitalisation expenses – The expenses incurred 30 days immediately prior to hospitalization & 60 days post hospitalization is covered. The cover is extended for a further 30 days in each case if claim is intimated 5 days prior to hospitalization.
Day care procedures – Due to technological advances, many conditions can be treated without the need for hospitalization ( like angiography ). 140 such procedures are coved under this policy.
Domiciliary treatment – The medical expenses incurred by an insured at his/ her residence on doctor’s advice, not in a position to be transported or room unavailability, is also covered.
Daily cash benefit - If a shared accommodation in a network hospital is chosen, a daily cash amount is given for every 24 hours of such hospitalisation.
Organ donor expenses – Hospitalisation expenses of the organ donor is paid, in an accepted inpatient hospitalization claim. Pre & post hospitalization expenses or any other treatment in respect of the donor is not covered in the policy.
Emergency Ambulance - This policy will reimburse ( upto Rs.2,000/- ) the expenses related to hiring an ambulance to transport the insured to the nearest hospital with adequate emergency facilities.
Daily cash for accompanying insured child - For a child aged 12 years or less, the policy will pay a daily cash amount ( Rs.500 per day, maximum Rs.3,000/- ) for one accompanying adult for each complete period of 24 hours if hospitalisation exceeds 72 hours.
Maternity Expenses - The policy will pay the Medical Expenses for a delivery (including caesarean section) while hospitalised or the lawful medical termination of pregnancy during the Policy Period ( limited to 2 deliveries or terminations or either during the lifetime of the Insured Person ). Waiting period – 4 years. Normal delivery – Rs.15,000/- & Caesarean delivery – Rs.25,000/-.
Newborn – Optional coverage - any medically necessary treatment while the Insured Person is hospitalised during the Policy Period as an inpatient for a Newborn Baby.
Critical illness – optional – An additional Sum Assured can be claimed ( over and above the medical insurance entitlement ) if the insured person is diagnosed with such an illness and survives a 30 day period. This will not affect the cumulative bonus entitlement.
Outpatient Module –
An entitlement certificate will be issued using which the following benefits can be accessed-
Outpatient Consultations - Outpatient consultation by a general / specialist Medical Practitioner can be availed of in a Network Hospital. Four consultations in a year for one adult, six consultations for two adults & eight for three adults, can be availed of. Outpatient consultations in non-network hospitals will be on reimbursement basis ( subject to their limits )
Diagnostic Tests - Outpatient diagnostic tests taken by the Insured from a Network diagnostic centre (not necessary to be prescribed by Network Medical Practitioner).
Pharmacy - Medicines purchased by the Insured Person from a Network pharmacy, provided that such medicines have been prescribed in writing by a Medical Practitioner (not necessary to be Network Medical Practitioner).
Dental Treatment - Any necessary dental treatment ( not cosmetic ) taken by an Insured Person from a Network dentist, upto Rs.1000/- per policy year.
Spectacles / Contact Lenses - Either one pair of spectacles or contact lenses, prescribed by a Network Eye Specialist, subject to a maximum of Rs.1000/- per policy year
Annual Health Checkup - A health check-up for the Insured Person in a Network Hospital. For those below 18 or above 45, this facility will be available from the second year onwards.
Bonus
Carry Forward Bonus - 50% of the unused Entitlement Certificates can be carried forward to the next year, on renewals without a break. All except Annual health checkup entitlements can be carried forward.
Cumulative Bonus – A 10% of initial Sum Assured is offered as a bonus for a claim free year and if the policy has been renewed without a break. The maximum cumulative bonus shall not exceed 50% of the Sum Insured.
Exclusions
• 30 day waiting period or longer is applicable in the first policy year and not applicable later if policy is in force continuously.
• Special Waiting periods – 2 year waiting period is imposed on ailments like arthritis if non infective, calculus diseases of gall bladder and urogenital system, cataract, fissure/fistula in anus, hemorrhoids, pilonidal sinus etc. Covered from third year if policy has been in force continuously. Similarly for treatments like benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy, mastoidectomy etc.), dilatation and curettage (D&C), fibromyoma, joint replacement etc., the same conditions mentioned above apply.
• Pre-existing Conditions will not be covered until 36 months of continuous coverage have elapsed, since inception of the first Maxima Insurance policy. A waiting period of 1 year will apply, if the Insured Person was insured continuously and without interruption for at least 2 years under another Indian insurer’s individual health insurance policy for the reimbursement of medical costs for inpatient treatment in a Hospital.
• Any claim directly or indirectly, due to war, civil war, revolution etc. will not be covered. A breach of law with criminal intent, or intentional self injury or attempted suicide while sane or insane. Also not covered would be any insured participating in racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing. Claims arising due to abuse of intoxicants or hallucinogenic substances are not covered. There are others too…
• Non allopathic treatment
After I explained all these aspects, he wanted to know if it is a good product. I had no hesitation in answering that. It is a good product – no doubt there. Since there are so many features that no medical insurance typically covers, it is an ace. The premiums are consequently high. The only grudge is that the cover that can be taken is just Rs.3 Lakhs. Today, that is too little. If you were to take individual policies for each member, it becomes too costly. But then, one can take advantage of 80D benefit, which gives a deduction of upto Rs.15,000/-. That’s an added benefit, I reminded Amit.
He seemed satisfied. He was currently steering me to Lalit, a well known sweet shop to have Jalebi. I taunted him,”You want to have jalebi, now that you have a cover?”. He laughed & I joined in.
Published in Money Mantra in Feb 2010
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