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DEALING with the UNKNOWN

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Market Check

Cases are on an exponential Insurance Coverages seem

increase especially in the urban insufficient from multiple
cities with increased Testing’s parameters
being done by respective State PPE Kits not covered in Health
Governments Insurance Plans
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Innovative Solutions: Managing the Scarcity factor for
asymptomatic patients

Home Care Coverage Claims are NOT ADMISSIBLE Hotel Care Packages (proviso being under Hospital
under Health Insurance Policies (without Administration) are ADMISSIBLE under Health
Domiciliary Cover) Insurance Policies (with or without Domi Cover)
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The Problem Statement: Employee standpoint
S
T
R
E
S
S
Sum Insured
Private
Limits are not
Healthcare
Sufficient to

LEADING TO
Facilities
meet the
becoming Utilization of
Treatment Savings to meet
unaffordable
Cost Costs

Room Rents have been

increased and beyond
my eligibility Employee Dissonance
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The Problem Statement: HR / Finance standpoint

DIP
in
Employee
Mid-term Satisfaction
policy changes Index
Economic

LEADING TO
not being
condition in
allowed by
general
Insurance
Companies

Excessive Utilization of Managing Employee

Corporate Buffer / Expectations
Insurer’s inability to
increase Limits
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What do we do? Is there a SOLUTION?
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The 3 Elephants in the ROOM

Higher Room
Rent Concerns

Sum Insured Home / Hotel

Limits Care Coverages
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Enhance
• Not allowed by
Corporate
Regulation mid-term
Buffer Limit

• Solves the Issue of OR

Enhance Limit
Top-Up
Plan Limits • Doesn’t address the
Room Rent Issue
CONSIDER A
NEW COVER
• Home Care: Not
OPTIONS allowed (except
Introduce policies with Domi
Home / Cover)
Hotel Care
• Hotel Care issue solved
by Regulation
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H
Sum Insured O
Limits
ranging from S
INR 50,000 P
to INR I
500,000 T
Co-morbidity No Room
treatment Rent A
covered Corona Restriction L
Indemnity
Cover
C
COVID-19 A
Positive S
Patients Home /
Entry Age of H
Hotel Care
0-65 years
Coverage
B
Individual
and Floater E
Option N
Available E
F
I
T
ADDRESSES all the ISSUES except PARENTAL COVER (> 65 years) and
Waiting period of 15 days
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0 So, what do we do
Consider buying an Individual Existing Company provided Base
Super Top-Up Health Insurance for and Top-Up Plan
Self, Spouse and 2 Children RESERVE for Parental Treatment
Create your own PERSONAL (> 65 years) if required
SECURITY

Buy INDIVIDUAL (not

Floater)
CORONA KAVACH
policies
for
Non COVID-19 Treatment
Trigger the Company Plan Self, Spouse, 2
Children and Parents
COVID-19 treatment
Trigger the Corona Kavach (< 65 years)
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1 Individual Policies OR Family Floater Policy
I
• Higher Sum Insured Limits for EVERY family member, ESSENTIAL in
N today’s circumstances
D PROS
• If one family member tests POSITIVE, chances are HIGH that other
I members could also test POSITIVE, sooner than later
P
V
L
I
A SAVING FEW THOUSAND
D
N CONS • Floater Discount not available RUPEES IN PREMIUM ?
U
A
L
OR
COMPROMISING FEW LACS OF
SUM INSURED LIMITS ?
F
F PROS • Floater discount available
L
A
O CHOOSE WISELY
M
A
I
T
L • Multiple COVID-19 treatments within family members could result
E CONS in INSUFFICIENCY in Sum Insured Limits
Y
R • We could be BACK to SQUARE ONE
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2 Benefits: CORONA KAVACH
Sum Insured Type On Individual basis – SI shall apply to each individual insured

Sum Insured Limits INR 50,000 to INR 500,000

Waiting Period 15 days

Covid-19 Tests Covered (as per doctor’s advice, no restriction on number of tests)

Age Limit 0 - 65 years (at entry)

Employee / Spouse / Children / Parents / Parents in law (entry age < 65

Who can BUY
years)

Room rent / ICU Restriction No restrictions

PPE / Protective Equipment Costs Covered

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3 Benefits: CORONA KAVACH
Pre | Post hospitalization days 15 and 30 days respectively

Ayush Treatment Covered (without any limits)

Home Care Treatment Covered (administered by Hospital)

Road Ambulance maximum of Rs.2000/- per hospitalization

Daily Cash YES

Types of hospitals covered Network Hospitals of Insurer / TPA

Restriction on Number of Days of Hospitalization NO

The Policy includes the cost of treatment for any co-morbid condition
Co-Morbid Conditions including pre-existing comorbid condition (s)along with the treatment for
Covid.
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4 Benefits: CORONA KAVACH – Hospital Cash
(Optional Cover)

Srl. No Details

1 Optional Cover

0.5% of sum insured per day for each 24 hrs of continuous hospitalization for treatment of Covid following an
2
admissible hospitalization claim under this policy.

3 The benefit shall be payable maximum up to 15 days during a policy period in respect of every insured person.
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5 Comparison of Benefits: CORONA KAVACH vs
GROUP MEDICLAIM POLICY
Srl.
Details GMC Policy Corona Kavach Remarks (if any)
No
Floater OR Individual Sum Individual Sum Insured Limits
1 Sum Insured Limit Floater
Insured should be considered
Linked to Base Policy Sum Insured
2 Room Rent / ICU Restrictions No Restrictions Corona Kavach - Superior
Limit as a % of SI Limit
Children: No Restriction
Who can be covered (apart from Children: < 25 years Children: Corona Kavach Superior
3 Parents: Up to 65 years (entry
Employee and Spouse) Parents: Generally till 80-100 Parents: GMC Policy Superior
age has to be < 65 years)

4 Home Care Coverage Not Covered Covered Corona Kavach: Superior

5 PPE Kits Not payable Payable Corona Kavach: Superior

Covered, proviso being result of

COVID-19 test being POSITIVE
6 Pre-Existing Diseases Covered Both are same
Pre-existing co-morbidities is
covered
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6

Choose
Declare Premiums
Log on to Sum Premium
names of (with GST)
India Insured deducted
Family displayed
Insure Limit and form
Members &
Portal Optional Payroll
with Age CONFIRM
Plan

A seamless Buying Process

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7 Premiums: Non-Floater Sum Insured
Sum Insured For 9,1/2 Months For 6,1/2 Months For 3,1/2 Months
S.No
(INR) Age in completed years* Age in completed years* Age in completed years*
Up to 40 41-60 Above 60 Up to 40 41-60 Above 60 Up to 40 41-60 Above 60
1 50,000 257 343 514 208 277 416 127 170 254

2 100,000 434 579 868 351 468 701 215 286 429

3 150,000 595 793 1,189 481 641 961 294 392 588

4 200,000 743 990 1,485 600 800 1,200 367 490 735

5 250,000 876 1,168 1,752 708 944 1,416 433 578 867

6 300,000 932 1,243 1,864 753 1,005 1,507 461 615 923

7 350,000 1,061 1,414 2,122 857 1,143 1,715 525 700 1,050

8 400,000 1,125 1,500 2,250 909 1,212 1,819 557 742 1,113

9 450,000 1,246 1,661 2,491 1,007 1,342 2,013 616 822 1,233

10 500,000 1,286 1,714 2,572 1,039 1,386 2,078 636 848 1,272

Premium Numbers without GST

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8 Premiums: Floater Sum Insured
Sum For 9,1/2 Months
S.No Insured Srl.
Age in completed years*
(INR) Insured Member’s Age Premium (w/o GST)
Up to 40 41-60 Above 60
No
1 50,000 257 343 514

2 100,000 434 579 868

100% of Base/Individual
3 150,000 595 793 1,189 premium as applicable for
1 Member with highest age that age and sum insured
4 200,000 743 990 1,485

5 250,000 876 1,168 1,752

6 300,000 932 1,243 1,864 Discount to be applied as

All other members with lower ages per Table A on
7 350,000 1,061 1,414 2,122 2 (i.e. All members other than the Base/Individual Premium of
Primary Member) every member
8 400,000 1,125 1,500 2,250

9 450,000 1,246 1,661 2,491

10 500,000 1,286 1,714 2,572

3 FINAL FLOATER PREMIUM ADD Sr. No. 1 & 2

Premium Numbers without GST

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9 Premiums: Example (Sum Insured Limit of INR 5.00 lacs)
Srl. No Relationship Age
1 Self 43
2 Spouse 41
3 Child 1 16
4 Child 2 12
5 Father 61

INDIVIDUAL SUM INSURED – INR 5 LACS EACH FLOATER SUM INSURED – INR 5 LACS
Srl. No Relationship Premium Srl. No Relationship Premium
1 Self 1,714 1 Self 686.00
2 Spouse 1,714 2 Spouse 686.00
3 Child 1 1,286 3 Child 1 514.40
4 Child 2 1,286 4 Child 2 514.40
5 Father 2,572 5 Father 2,572.00
TOTAL 8,572 TOTAL 4,973
Premium Numbers in INR without GST
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0 Premiums: Hospital Cash (Optional Cover)

Sum Insured For 9,1/2 Months For 6,1/2 Months For 3,1/2 Months
S.No.
(INR) Age in completed years* Age in completed years* Age in completed years*

Upto 40 41-60 Above 60 Upto 40 41-60 Above 60 Upto 40 41-60 Above 60

1 50,000 12 16 23 9 13 19 6 8 12

2 100,000 23 31 47 19 25 38 12 15 23

3 150,000 35 47 70 28 38 57 17 23 35

4 200,000 47 62 93 38 50 75 23 31 46

5 250,000 58 78 117 47 63 94 29 38 58

6 300,000 70 93 140 57 75 113 35 46 69

7 350,000 82 109 163 66 88 132 40 54 81

8 400,000 93 124 186 75 100 151 46 61 92

9 450,000 105 140 210 85 113 170 52 69 104

10 500,000 117 155 233 94 126 188 58 77 115

Premium Numbers without GST

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Annexures
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2 Coverages: CORONA KAVACH
COVID-19 POSITIVE CASE: HOSPITALIZATION BENEFITS
Srl. No Coverage

1 Room, Boarding, Nursing Expenses as provided by the Hospital / Nursing Home

Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees (including consultation through telemedicine as per Telemedicine Practice
2
Guideline of 25th March 2020) whether paid directly to the treating doctor / surgeon or to the hospital

Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, ventilator charges, medicines and drugs, costs towards diagnostics,
3
diagnostic imaging modalities, PPE Kit, gloves, mask and such other similar expenses

4 Expenses on Hospitalization for a minimum period of 24 hours are admissible

5 Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses

6 Expenses incurred on road Ambulance: Maximum of Rs.2000/- per hospitalization.

7 Expenses incurred by the insured person for the treatment of Covid on Positive diagnosis of Covid in a government authorized diagnostic centre
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3 Coverages: CORONA KAVACH
COVID-19 POSITIVE CASE: HOME CARE BENEFITS
Srl. No Coverage
1 Max. upto 14 days per incident, provided conditions noted as under

2 Advices by Medical Practitioner to undergo treatment at home

Continuous active line of treatment with monitoring of the health status by a medical practitioner for each day through the duration of the home
3
care treatment
4 Daily monitoring chart including records of treatment administered duly signed by the treating doctor is maintained

5 Cashless or reimbursement facility offered: subject to claim settlement policy of the Insurer
In Case of services of non-network provider : Reimbursement mode only and a prior approval from the Insurer needs to be taken before availing
6
such services. Insurer shall respond to approval request within 2 hrs of receiving the last necessary requirement
7 In this benefit, the following shall be covered if prescribed by the treating medical practitioner and is related to treatment of COVID,

a Diagnostic tests undergone at home or at diagnostics centre,

b Medicines prescribed in writing

c Consultation charges of the medical practitioner

d Nursing charges related to medical staff

e Medical procedures limited to parenteral administration of medicines

f Cost of Pulse oximeter, Oxygen cylinder and Nebulizer

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4 Exclusions
Srl. No Exclusions

1 Only for Investigation & Evaluation

2 Rest Cure, rehabilitation & respite care

3 Non Prescribed Dietary Supplements

4 Unproven treatments

5 Covid Diagnosed prior to policy date

6 Day care & OPD

7 Treatment Outside Geographical Limits of India

8 Testing at Non-Government Authorised Diagnostic Centres

9 All Covers would cease: On Travel to any country placed under travel restriction by the Government of India.
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5 Claim Settlement: Cashless

Srl. No DETAILS
Treatment may be taken in a network provider and is subject to preauthorization by the Company or its authorized
1
TPA

Cashless request form available with the network provider and TPA shall be completed and sent to the Company/TPA
2
for authorization

The Company/ TPA upon getting cashless request form and related medical information from the insured person/
3
network provider will issue pre-authorization letter to the hospital after verification.

At the time of discharge, the insured person has to verify and sign the discharge papers, pay for non-medical and
4
inadmissible expenses

The Company / TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the
5
relevant medical details

In case of denial of cashless access, the insured person may obtain the treatment as per treating doctor’s advice and
6
submit the claim documents to the Company / TPA for reimbursement
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6 Claim Settlement: Reimbursement (Hospitalization Claim)

1. Duly filled and signed Claim Form

2. Copy of Insured Person’s passport, if available (All pages)
3. Photo Identity proof of the patient (if insured person does not own a passport)
4. Medical practitioner’s prescription advising admission
5. Original bills with itemized break-up, Payment receipts
6. Discharge summary including complete medical history of the patient along with other details.
7. Investigation reports including Insured Person’s test reports from Authorized diagnostic centre for COVID
8. OT notes or Surgeon’s certificate giving details of the operation performed, wherever applicable
9. Sticker/Invoice of the Implants, wherever applicable.
10. NEFT Details (to enable direct credit of claim amount in bank account) and cancelled cheque
11. KYC (Identity proof with Address) of the proposer, where claim liability is above Rs 1 Lakh as per AML Guidelines
12. Legal heir/succession certificate, wherever applicable
13. Any other relevant document required by Company/TPA for assessment of the claim.
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7 Claim Settlement: Reimbursement (Home Care Claim)
1. Duly filled and signed Claim Form
2. Copy of Insured Person’s passport, if available (All pages)
3. Photo Identity proof of the patient (if insured person does not own a passport)
4. Medical practitioners’ prescription advising hospitalization
5. A certificate from medical practitioner advising treatment at home or consent from the insured person on availing home care benefit.
6. Discharge Certificate from medical practitioner specifying date of start and completion of home care treatment.
7. Daily monitoring chart including records of treatment administered duly signed by the treating doctor is maintained.

Note:
1. The company shall only accept bills/invoices/medical treatment related documents only in the Insured Person’s name for
whom the claim is submitted
2. In the event of a claim lodged under the Policy and the original documents having been submitted to any other insurer,
the Company shall accept the copy of the documents and claim settlement advice, duly certified by the other insurer
subject to satisfaction of the Company
3. Any delay in notification or submission may be condoned on merit where delay is proved to be for reasons beyond the
control of the Insured Person
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Stay SAFE
Stay HEALTHY
Maintain SOCIAL DISTANCING
Maintain GOVERNMENT PROTOCOLS