HEALTH SURAKSHA Health Insurance Plan

Health Suraksha
Financial Assistance for you and your family against Hospitalisation Expenses incurred towards disease / illness / injury in India along with other additional benefits.

Health Suraksha

Basic Features Value Added Features Policy Features

Exclusions
Plan Details Our Advantage

Features

Hospitalisation Expenses

Daycare Treatment
Pre and Post Hospitalisation Coverage of Pre-Existing Diseases

(A) Hospitalisation
Policy covers hospitalisation expenses incurred as an in-patient in a Hospital which will include

Room, Boarding and Operation Theatre charges Fees of Surgeon, Anesthetist, Nurses, Specialists The cost of diagnostic tests, medicines, blood, oxygen, appliances like pacemaker, prosthesis/internal implants and any medical expenses incurred which is integral part

of the operation
Hospitalisation for a minimum period of 24 hours is a must except the day care procedures

defined under the policy.

(B) Day Care Treatment

Hospitalisation less than 24 hrs
Due to advancement of technology, hospitalisation expenses for certain treatments / diseases like the following are also covered, even though the hospitalisation is for less than 24 hours

Cardiac Catheterization Dilation & Curettage Eye Surgery Hernia Repair Surgery Hydrocele Surgery Lithotripsy (Kidney stone removal) Radiotherapy Tonsillectomy Cataract Chemotherapy Coronary Angiography Coronary Angioplasty Dialysis

For more Day Care Procedures (Total 100 defined), please refer to policy wordings

(C) Pre and Post Hospitalisation

Policy also covers relevant medical expenses incurred during a specified period, before & after hospitalization (for which a claim is payable) Policy Cover Pre-Hospitalisation upto 60 days. Policy Cover Post-Hospitalisation upto 90 days. For Limits, please check the Plan Slide

(D) Coverage of Pre-Existing Diseases

Definition:
Means any condition, ailment or injury or related condition(s) for which You had signs or symptoms, and / or were diagnosed and / or received medical advice/ treatment, within 48 months prior to inception of your first policy with Us Hospitalisation expenses incurred on treatment towards Pre-existing diseases / condition can be covered:

After completition of 4 years of Consecutive years of policy with FG.

2. Additional Benefits
Additional benefits are payable up to the limits specified
.

Local Road Ambulance Services Free Medical Health Check up Patient Care Hospital Cash Expenses on accompanying person at the Hospital Accidental Hospitalisation. These features become applicable once a valid claim is admitted under the basic hospitalisation expenses cover of the Policy

(A) Local Road Ambulance Services

Reimbursement of Expenses incurred for necessary transportation of the insured to the Hospital in an ambulance for hospital admission and requiring immediate treatment.

Benefit under this extension is limited to 1% of the Sum Insured per policy period

subject to maximum of INR 1500/-

(B) Cost of Health Check up

This benefit provides for reimbursement of cost / charges incurred for medical check up.

Applicable once at the end of a block of 4 claim free years. Reimbursement is as follows: - Individual Plan: 1% of the sum Insured subject to maximum of INR 2,500/- Family Floater Plan: For 2 People : 1% of the sum insured subject to maximum of INR 4,000/-

(C) Patient Care Allowance

Payment of Nursing Allowance for expenses towards employment of registered nurse at the

residence of Insured such services are: Confirmed as being necessary by the treating Physician Relate directly to a disease / illness / injury for which the Insured has been hospitalised. This is applicable for people above 60 years advised nursing at Home after discharged from hospital. Allowance is payable for 10 days for any single Hospitalization @ Rs 350/- per day or actuals whichever is lower

Maximum Day allowance is 30 days during the policy period.

(D) Hospital Cash Allowance

The Extension is only applicable for Platinum Plan Holder. The allowance of Rs.500/- per day is allowed for each completed day of Hospitalization subject to Maximum 60 days during a policy period. It is irrespective of the number of occurrences If case two people of the same floater are hospitalized, concurrently, each one of them will be eligible for hospital daily allowance separately subject to max allowable policy limit.

(E) Expenses on Accompanying Person

For Hospitalisation of Child less than 10 Years. Company will pay additional Rs.500/- for each completed day of Hospitalisation subject to maximum of 30 days during the Policy period Accompanying person means and includes mother, father, grandmother, grandfather or any immediate family member.

(F) Accidental Hospitalization

Increase Limit of Sum Insured available if Hospitalization is due to an accident. Enhancement of Limits by 25% of Available Sum Insured at the Time of Hospitalization due to an accident subject to 1 Lakh.

3. Policy Features

Income Tax Benefit

Individual Plan & Family Floater Plan

Sum Insured Pre-insurance Health Check up

Option in Policy Duration

Renewal Discount Cashless Facility (Through Third Party Administrators - TPA) Age Slabs

(A) Income Tax Benefit

Premium paid for Health Suraksha Policy is eligible for tax deduction under section 80 D of the Income Tax Act, subject to the condition that the premium amount is paid by any mode, other than cash Rs. 15,000/- for self, spouse & Dependent Children. Rs.15,000/- towards the Health premium for parents. Rs. 20,000/- if the policy includes senior citizens whose ages is above 65 yrs

Options Available
Policy can be Opted for Individual Plan & Family Floater Plan

Individual Plan Health Suraksha (Individual):

Each member has a liberty to chose their own limits and has advantage to utilize it to 100% during the policy period. Has an option to start with a sum insured as low as 100000 /- to Rs. 10 Lakh Subject to Medical approval based on age and Sum Insured. Sum insured of 50000 can be taken for children only Parents can be also covered in same plan upto the age of 70 years subject to medical and maximum Sum Insured of 5 Lakh. 10% Family Discount is applicable in the policy if the insureds are more than one.

Renewal Discount & Cumulative Bonus:

Would be applicable to the members in the policy who have a claims free year of policy for first 5 years. Each claim free year would have an entitlement of 5% discount on the renewal premium. From 6th Year, each member would get entitled of Cumulative Bonus of 10% on the basic sum insured upto maximum of 50% of the sum insured for every claim free year.

Claims Experience Loading

At renewal claims experience loading is charged only on the individual who has made the claim and not on other members covered under the policy.

Plan Available under Health Suraksha (Individual)

Structuring of Plans based on Geographical classification. Geographical Classification is based on differential Medical Treatment cost in various city. Why a person living in Bhopal should pay premium equivalent to Delhi/Mumbai, where the cost of treatment is higher as compared to Bhopal? Geographical Classification. Zone A (Mumbai ,Thane and Panvel & Delhi & NCR) Zone B (Chennai, Kolkata, Ahmedabad, Hyderabad & Bangalore) Zone C ( All other cities in the country except defined in Zone A & B) Zone C will have lower premium than Zone B and Zone B would have lower premium than Zone A for similar benefits.

Plan Details

Basic Plan: Available for Zone C. Silver Plan: Available for Zone B. Gold Plan: Available for Zone A Platinum Plan: Across India. What if I opt for Basic Plan (Applicable for Zone C) and take treatment in Zone A. I have paid Lower premium for Zone C and I decide to take a treatment at high Medical Treatment Zone A. Company would deduct the %tage from the approved claim amount. The Next Slide will reflect these deductions in claim amount when there is a difference in Plan opted and Zone of Treatment.

Deduction in Claims
(When Plan opted and Treatment Zones are different)

Benefit Plan Platinum Plan Gold Plan Silver Plan Basic Plan

Zone A 100%* 100%* 80%* 70%*

Zone B 100%* 100%* 100%* 80%*

Zone C 100%* 100%* 100%* 100%*

*The percentage of claim amount shown in the above table is with respect to the eligible claim amount. Eg. If a person opts for Platinum or Gold plan, treatment taken irrespective of location (Zone), 100% of Approved claim amount is paid If a person opts for Silver and takes treatment in Zone A geography is paid only 80% of the approved claim amount. If Person opts for Basic and takes treatment in Zone A or Zone B, is paid only 70% of the approved claim amount.

Benefit under various Plans

S r # 1 Room, Board & Nursing Expenses & Service . Charges Etc a If admitted into Intensive Care Unit . b All admissible claims under 1.(a) & 1.(b) during the . policy period c Surgeon, Anaesthetist,Consultants, Specialists Fees Anaesthesia, Blood, Oxygen, OT Charges, Surgical Appliances Pre-hospitalisation expenses- 60 days Scope BASIC,SILVER & GOLD Upto 1% of the SI per day As per Actuals Payment PLATINUM

Upto 2% of the SI per day

As per Actuals

Upto 35% of the Sum Insured per claim

As per Actuals

2. 3 4.

Upto 35% of the Sum Insured per claim Upto 40% of the Sum Insured per claim Upto 8% of the eligible per hospitalisation expenses.

As per Actuals As per Actuals Upto 8% of the eligible per hospitalisation expenses.

5.
6. 7. 8.

Post hospitalisation expenses-90 days

Day Care Expenses Ambulance charges Free medical check-up

Upto 10% of the eligible per hospitalisation expenses.

Around 100 day care procedures. Upto 1% of SI per policy period up to a max of Rs. 1500 For every 4 claim free years- free medical check-up - 1% of SI up to a max of Rs. 2500, For FF(2-people) - 1% of SI up to a max of Rs. 4000. Above 60 years-attendant nursing charges after discharge from the hospital @ Rs 350/- per day or actuals whichever is lower up to a max 10 days -subject to max of 30 days during the policy period. Limits under the policy shall increase by 25% of the balance sum insured available subject to max of Rs.1 Lacs NA Rs 500/- for each completed day of hospitalisation in case of a child up to age of 10 years subject to max of 30 days. Accompanying person means and includes mother, father, grand father, grand mother, any immediate family member.

Upto 10% of the eligible per hospitalisation expenses.

Around 100 day care procedures. Upto 1% of SI per policy period up to a max of Rs. 1500 For every 4 claim free years- free medical check-up - 1% of SI up to a max of Rs. 2500, For FF(2-people) - 1% of SI up to a max of Rs. 4000. Above 60 years-attendant nursing charges after discharge from the hospital @ Rs 350/- per day or actuals whichever is lower up to a max 10 days -subject to max of 30 days during the policy period. Limits under the policy shall increase by 25% of the balance sum insured available subject to max of Rs.1 Lacs Rs 500/- for each completed day of hospitalisation subject to max of 60 days. Rs 500/- for each completed day of hospitalisation in case of a child up to age of 10 years subject to max of 30 days. Accompanying person means and includes mother, father, grand father, grand mother, any immediate family member.

9.

Patient Care

Accidental Hospitalisation 0 Hospital Cash 1 Accompanying Person 2

1 1

Eligibility
Age Eligibility
Age from 5 Years to 70 Years. Children above 90 days of age can be covered under the policy, if the parents are also covered

at the same time with Future Generali.

Sum Insured Eligibility

Sum Inured under Gold, Silver & Basic plan: Rs.1,00,000/- To Rs. 5,00,000/ Sum Insured under Platinum Plan: Rs. 6,00,000/- To Rs. 10,00,000/-

Underwriting guidelines
Acceptance Limit

Age at entry is restricted to 70 years Family floater policy the eldest age will be considered for premium calculation. Family floater policy age entry (age for the eldest family member) is restricted to 45 years.

Children above age of 90 days eligible if the parents are concurrently insured with Future Generali
Minimum SI limit for Individual cover to be 100,000.SI of 50000 can be availed by children

ROLL OVER CASES

For person who already have an ongoing policy with the any Insurance Company

Up to 45years -no claim in the previous policy year accept and allow them the NCB One year policy with any insurer and no claim Accept with eligible CB and 1st year exclusion is waived. 2 year policy with any insurer and no claim Accept with eligible CB and 1st year & 2nd year exclusion is waived 3 year policy with any insurer and no claim Accept with eligible CB and 1st year & 2nd year & 3rd year exclusion is waived But in any case pre-existing exclusion waiver applicable only after completion of 4 years with FGI

Above 45 years accept as fresh case with out no claim bonus

ROLL OVER CASES

Renewal Discount and Renewal No Claim bonus The maximum cumulative bonus shall be 50% for those policies where

there is no CB at the time of inception of this policy with FG.For Policies which have CB at the time of inception of the first policy with FG the Cumulative bonus shall be restricted to max 70%. At 6th year in case of no claims the maximum discount availed would be 25% on the renewal premium and 10% cumulative bonus on the expiring sum insured. The discount of 25% on renewal premium will be applicable for succeeding year provided there are nil claims. Incase of a claim in the Policy the Renewal premium discount will be nil and the Cumulative Bonus will get reduced by 20% for each claim year. Transfer of CB from previous floater policy to the new floater policy or to an individual policy is not possible.

MEDICAL UNDERWRITING GUIDELINES

Taking into account the proposal form and /or the medical reports following restrictions & loadings are applicable.The final acceptance of the proposal will be decided by the underwriter. 0-35 years 36-45 years

Smoker
Hypertension Diabetes

10% loading on the standard rates

Decline 20% loading on premium accept with Diabetes and related conditions exclusion 10% loading on standard premium accept with exclusion Decline

Ask for FMR, ECG, Lab1 & X-ray Chest

Asthma

Combination of any 2 or more of (b), (c), (d) Any positive history of any other ailment

For sum insured up to 5 lacs can be decided by the underwriting office after obtaining medical opinion from the Zonal Underwriter. Above this please consult HO.

Age Of the Person to be Insured

Sum Insured

Medical Examination

Tests Required

Under 45 years

Up to 5 lacs

Not required. Subject to the proposal forms being clean of any previous illness/diseases/surgeries.
Required Not required Required Required FMR, ECG, Lab1, X ray Chest, lipid profile FMR, ECG, Lab1, X ray Chest, Lipid profile FMR, ECG, Lab1, X ray Chest

Under 45 years Between 46-55 years Between 46-55 years Above 55 years

Over 5 lacs Up to 3 lacs More than 3 lacs for all sum insured

Max Sum Insured available for the Person above 55 years will Be Rs 5 Lacs

FMR: Full Medical Report by a MD Physician ECG: Electrocardiogram conducted by the MD Lipid Profile Lab 1: includes Fasting Blood Glucose, post prandial blood sugar, Complete Blood Count (incl Diff), Serum Cholesterol, Serum Creatinine, Urinalysis (chemical & microscopic) X - Ray Chest.

Premium for Health Suraksha (individual)

Premium is calculated on the basis of Plan, Sum Insured and Age. Age to be taken as Completed Age.

Renewal Terms

Renewal Premium would be based on Age Band and claim experience. Loading based on Claim Frequency and Claim amount.

Life Time Indemnity

Insured subscribing to FG Health Suraksha for 1st Time, after 50 Years of age The Life Time Indemnity Limit is 3 Times of Sum Insured specified in earliest Health Suraksha Plan, if policy is renewed continuously.

Floater Plan
Health Suraksha Family Floater Family Floater
Policy can be issued on a Floater basis covering the family members of the Insured comprising the Insured, spouse and two dependant children (upto the age limit of 21 years).
What is floater, how does it benefit?

All members of the family (Self, Spouse, 2 Kids) can be covered under one single policy Single premium payable for the entire family The amount of Sum Insured floats over the entire family

No need to insure individual members separately

No hassles of tracking renewals for different members

Family Floater - Illustration

Family: Mr. John Smith, Mrs. Smith & their kid Dooby Scenario 1:

They take an insurance policy with a SI of Rs.1 Lakh each Mr. Smith unfortunately needs to undergo Heart Bypass The total bill amount Rs. 2 lakhs Insurance company pays only Rs. 1 Lakh as he is covered for only 1 Lakh. He cannot adjust the rest in the unused coverage amount of his wife and daughter

Mr. Smith needs to bear the reminder of the cost i.e. Rs, 1,00,000/-

Family Floater - Illustration

Family: Mr. John Smith, Mrs. Smith & their kid Dooby Scenario 2:

They take a Health Suraksha Family Floater with a SI of Rs. 3 Lakh for the family

Mr. Simth unfortunately undergoes Heart Bypass

The total bill amount Rs. 2 lakhs The entire amount is paid by Future Generali Mr. Smith does not need shell out any money out of his own pocket

Still 1 lakh is Left Unutilized for the policy period for the family.

Your Choice!

OR

Advantage Floater!
Chance of all in Mr.Simth family falling ill in one year is low as compared to one member falling severely ill Theory of probability

Individual
Single cover for each member No flexibility to transfer the unutilized limit for other members Separate policy (separate document) for family members

Floater
Common cover for all members The limit can be used by any member of the family & for any number of times Single document, single premium, single date to track

Fits all in the Family

Family covered under floater policy Choice of cover Couple

Couple & One kid

Couple & Two kids Individual & One Kid Individual & Two Kids

Choice of cover amount Rs. 2 to 10 Lakh per family depending on the plan selected

Plan Details

Basic Plan: Available for Zone C. Silver Plan: Available for Zone B. Gold Plan: Available for Zone A Platinum Plan: Across India.

What if I opt for Basic Plan (Applicable for Zone C) and take treatment in Zone A. I have paid Lower premium for Zone C and I decide to take a treatment at high Medical Treatment Zone A. Company would deduct the %tage from the approved claim amount. The Next Slide will reflect these deductions in claim amount when there is a difference in Plan opted and Zone of Treatment.

The other terms and conditions are same as that of Individual Health Suraksha.

Eligibility
Age Eligibility
Age from 5 Years to 45 Years. Children above 90 days of age can be covered under the policy, if the parents are also covered

at the same time with Future Generali.

Sum Insured Eligibility

Sum Inured under Gold, Silver & Basic plan: Rs.2,00,000/- To Rs. 5,00,000/ Sum Insured under Platinum Plan: Rs. 6,00,000/- To Rs. 10,00,000/-

Exclusions

Certain diseases like cataract, hernia , tumors shall be covered after a waiting period of 2 years. Certain diseases/surgeries like gallstones, renal stones shall be covered after a waiting period of 1 year. Any condition, ailment or injury or related conditions for which you have been diagnosed, received medical treatment, had signs and / or symptoms, prior to inception of your first policy, until 48 consecutive months have elapsed, after the date of inception of the first policy with Future Generali. Joint replacement surgery shall be covered after a waiting period of 3 years except done due to an accident.

Any disease contacted during the first 30 days of inception of policy accidents excluded and roll over cases excluded
Non-allopathic treatment Pregnancy & childbirth related diseases

Premium chart For Family Floater

CLAIMS PROCESS

Types of claims
Hospitalisation
Claims can be broadly of two types:

Reimbursement claims Cashless claims Through our TPA Dedicated Health Services Limited

This further can be broken into:

Planned - Where the customer is aware of the hospitalisation atleast 72 hours in advance

Emergency - Where the customer meets with an accident or suffers from bout of illness that requires immediate admission to the hospital

Claims are serviced at both network as well as non-network hospitals

Network hospitals Hospitals which are on the tied up list (more than 3000 hospitals covered) Where our service provider has a relationship Non-network hospitals which do not form part of the list

Reimbursement
Steps to follow during hospitalisation A) Emergency hospitalisation

Step 1. Take admission into the hospital. Step 2. As soon as possible, inform TPA about the hospitalisation. Step 3. At the time of discharge, to settle the hospital bills in full and collect all the original bills, documents and reports. Step 4. Lodge the claim with TPA for processing and reimbursement by duly filling in the claim form & enclosing all original bills/vouchers/receipts

B) Planned hospitalisation

Step 1. Inform TPA about the planned hospitalisation. Step 2. Get admitted into the hospital as planned. Step 3. At the time of discharge, to settle the hospital bills in full and collect all the bills, documents and reports. Step 4. Lodge the claim with TPA for processing and reimbursement by duly filling in the claim form & enclosing all original bills/vouchers/receipts

Reimbursement Claims
Claim procedure

As soon as hospitalised, to intimate the TPA (Help line/Toll free number mentioned in the Health Card) Following information needs to be furnished while intimating a claim:

Contact Numbers Policy Number (as reflecting on the Health Card) Name of Insured person who is Sick or Injured Nature of Sickness/Accident Date & Time in case of accident, commencement date of symptom of disease in case of sickness Location of accident

Cashless Claims
Procedure (Approval)
Cashless Service is the service wherein the Insured need not pay any money at the time of

admission or discharge.

This facility is available only at our Network Hospitals Cashless Request Form available in network hospital is to be filled up and sent to TPA for getting authorisation from TPA. The Hospital will coordinate for this. This authorisation along with a copy of the Health Card has to be given to the Network Provider at the time of admission Please also keep a copy of any photo ID card, it may be required by the Hospital.

To avail the Cashless Service

TPA will authorize Cashless Service at the Network Hospitals for all cases which are covered under the policy.

Cashless Claims
Procedures (Denial)

Cashless Service may be denied in following situations:

In case of any doubt in the coverage of treatment of present ailment under the Policy If the information sent to TPA is insufficient to confirm coverage The ailment/condition etc. not being covered under the policy If the request for pre-authorisation is not received by TPA in time

Denial of Cashless Service is not denial of treatment. The Insured can continue with the treatment, pay for the treatment to the hospital and after discharge send the claim to TPA for processing.

Cashless Claims
Procedures for emergency hospitalisation

Rush to hospital and get admitted. Obtain the Pre-Authorisation Form from the hospital (if it network). Get the same filled in & signed by the attending doctor with required details. Fax the pre-authorization form along with necessary medical details to TPA at the number

mentioned in health card. The Hospital will coordinate for this.

Cashless Claims
Procedures for emergency hospitalisation

If pre-authorisation is received from the TPA for Cashless Service

At the time of discharge.

Verify the bills and sign on all the bills at the Hospital.

Pay only for those items that are not reimbursable under the Policy (Hospital / TPA will guide in this).
Leave the original discharge summary & other investigations reports with the hospital. Retain a Xerox copy for records.

Cashless Claims
Procedures for Planned hospitalisation
Coordinate with hospital & send in all the details along with the Pre-Authorisation Form at least 2 days prior to the hospitalisation including the plan of treatment, cost estimates etc. to TPA.

If Cashless Service is authorised by TPA

At the time of admission, handover in the authorisation letter of TPA for cashless service & a photocopy of ID card to the hospital. At the time of discharge a. Verify the bills and sign on all the bills. b. Pay only for those items that are not reimbursable under the Policy. c. Leave the original discharge summary, other reports with the hospital. Retain a Xerox copy for records.

Thank you