SHRI RGP GUJARATI PROFESSIONAL INSTITUTE

A
RESEARCH REPORT
ON
HEALTH INSURANCE

ACADEMIC SESSION
2022-2023
SUBMITTED TO: SUBMITTED BY
(Director) MBA (3 rd Sem)
Shri Raoji Bhai Gokal Bhai Patel Gujarati Professional Institute
Indore (MP)
 ACKNOWLEDGEMENT

This is very special project brought to fruition through the efforts of some very special people. I am deeply grateful to all
those people whose enthusiasm and energy transformed my visions of this project into reality specially to Dr. Ravleen Kaur
(Director) because her commitment and sense of vision moves me and I am indebted to her for the help and the
encouragement.

My writing in this project has also been influenced by no. standard and popular text book in this field as for as possible,
they have been fully acknowledge at the appropriate places. I express my gratitude to all of them , I am also deeply grateful
to teachers for helping wherever it required in preparation of this project.

LAXITA
LANDE
 Contents

CHAPTER NO. DESCRIPTION

1 INTRODUCTION
2 REASERCH OBJECTIVES
3 BACKGROUND OF HEALTH INSURANCE IN INDIA
4 TYPES OF POLICIES
5 ADVANTAGES AND DISADVANTAGES
6 DATA ANALYSIS
7 BENEFITS OF FAMILY HEALTH INSURANCE
8 TYPES OF HEALTH INSURANCE
9 COMPANY AND PRODUCTS
 Introduction

 Health insurance is one of the important approaches that can help in boosting universal healthcare coverage through
improved healthcare utilisation and financial protection. This objectives of this review are to identify various interventions
implemented in India to promote awareness of health insurance, and to provide evidence for the effectiveness of such
interventions on the awareness and uptake of health insurance by the resident Indian population.
The Universal Health Coverage (UHC) is embedded within the Sustainable Development Goals (SDGs) and aims ‘to ensure
healthy lives and promote well-being for all at all ages by 2030’.It includes financial risk protection and equal access to
quality essential healthcare services . In other terms, UHC encourages equitable healthcare and nations across the world
are committed to achieving SDGs through UHC.
Health insurance is one of the important approaches that can help in boosting UHC through improved healthcare
utilisation and financial protection. There are multiple types of insurance in LMICs that differ with providers (government
vs private sector), scales and types of beneficiaries. However, in many LMICs, due lack of acceptability and unwillingness
to pay (WTP) premiums, health insurance coverage is limited. This increases the risk of excluding vulnerable and at-risk
population, who cannot afford to pay health insurance premium. Additionally, the older adults, and the individuals with
disability and chronic diseases, have less probability of enrolling in health insurance schemes or their specific needs may
not be covered under the scheme.
 RESEARCH OBJECTIVES

Demand for health care and for insurance: We place the potential customer at the centre of our research interest. We hope
to generate insight into the questions like;
1. What are the indirect (transactional) costs of seeking medical care?
2. Which institutional arrangement would the clients prefer?
3. What redistribution justice is acceptable to the rural poor?
4. What kind of care do customers prefer (ayurvedic, unani, allopathic, homeopathic, other traditional), and why?
5. Perception of how individuals can manage risks?
6. what local systems are there?

Supply of healthcare: Nobody is likely to buy health insurance unless they can expect to get care locally.
1. We shall therefore look at available healthcare supply at each location.
2. We shall also distinguish suppliers by the type of care they provide (ayurvedic, unani, allopathic, homeopathic, other
traditional), and assess the fit to priorities of the customers.
3. Additionally, we shall look at sustainable product distribution (e.g. drugs, perishables), pricing and product development.

Supply of insurance: Extending coverage of insurance, increasing the number of people insured, contributing to efficiency
and stability of micro health insurance units in India is the overall goal of our work. To achieve this, questions like
1. How well do the poor understand insurance principles?
2. What is their willingness and ability to pay for health insurance? have to be answered.
3. How old aged people can be insured?
 BACKGROUND OF HEALTH INSURANCE IN INDIA

Launched in 1986, the health insurance industry has grown significantly mainly due to liberalization of economy and general
awareness. According to the World Bank, by 2010, more than 25% of India's population had access to some form of health
insurance. There are standalone health insurers along with government sponsored health insurance providers. Until
recently, to improve the awareness and reduce the procrastination for buying health insurance, the General Insurance
Corporation of India and the Insurance Regulatory and Development Authority (IRDAI) had launched an awareness
campaign for all segments of the population.
Launched in 2007, the National Health Insurance Program (Rashtriya Swasthya Bima Yojana- RSBY) is led by the Ministry of
Health and was adopted by 29 states in 2014. It is funded 75% by the government and 25% by the states. The worker and 4
of his dependents benefit from health insurance if they are not covered by any system and live below the poverty line. RSBY
beneficiaries are required to pay an annual registration fee of ₹30 for hospital coverage up to ₹30,000 per year per family.
On September 25, 2018, the Indian government announced the launch of a new health insurance for the poorest citizens.
Indian Prime Minister Narendra Modi announced that the new system is expected to reach more than 500 million people
and is called "Modicare". The reform is still in progress and aims to install universal social security in the country.
The Indian social protection scheme covers insured persons against risks related to old age, invalidity, death, but also
sickness and maternity, unemployment and finally accident at work and occupational diseases.

This social protection scheme is not universal and provides only limited coverage, targeting mainly organized sector's
workers constituting less than 10% of the population in India. All risks are placed under the supervision of
the Ministry of Labour and Employment.

Social security and health insurance is defined by 5 main texts in India:

The Employees' State Insurance Act, 1948;

Employees' Provident Funds & Miscellaneous Provisions Act, 1952;
The Employees (Workmen's) Compensation Act, 1923;
The Maternity Benefit Act, 1961;
The Payment of Gratuity Act, 1972;

Social security benefits are mainly managed by: Employees' State Insurance Corporation (ESIC) and Employees'
Provident Fund Organisation (EPFO)
 TYPES OF POLICIES
Health insurance in India typically pays for only inpatient hospitalization and for treatment at hospitals in India. Outpatient
services were not payable under health policies in India. The first health policies in India were Mediclaim Policies. In Year 2000,
Government of India liberalized insurance and allowed private players into the insurance sector. The advent of private insurers
in India saw the introduction of many innovative products like family floater plans, top-up plans, critical illness plans, hospital
cash and top up policies.
The health insurance sector hovers around 10% in density calculations. India is a country with one of the lowest health
insurance penetration, with only 18% of people in urban areas and 14% in rural areas covered under any kind of health
insurance scheme. One of the main reasons for the low penetration and coverage of health insurance is the lack of
competition in the sector. IRDAI which is responsible for insurance policies in India can create health circles, similar to telecom
circles to promote competition.
In principle, government health services are available to all citizens under the tax-financed public system. In practice,
bottlenecks in accessing such services compel households to seek private care, resulting in high out-of-pocket payments.
Health insurance plans in India today can be broadly classified into these categories:

•Hospitalization

Hospitalization plans are indemnity plans that pay cost of hospitalization and medical costs of the insured subject to the
sum insured. The sum insured can be applied on a per member basis in case of individual health policies or on a floater
basis in case of family floater policies. In case of floater policies the sum insured can be utilized by any of the members
insured under the plan. These policies do not normally pay any cash benefit. In addition to hospitalization benefits,
specific policies may offer a number of additional benefits like maternity and newborn coverage, day care procedures for
There is another type of hospitalization policy called a top-up policy. Top up policies have a high deductible typically set a
level of existing cover. This policy is targeted at people who have some amount of insurance from their employer. If
the employer provided cover is not enough people can supplement their cover with the top-up policy. However, this is
subject to deduction on every claim reported for every member on the final amount payable.

•Family Floater Health Insurance:

Family health insurance plan covers entire family in one health insurance plan. It works under assumption that not all
member of a family will suffer from illness in one time. It covers hospital expense which can be pre and post. Most of
health insurance companies in India offering family insurance have good network of hospitals to benefit the insurer in
time of emergency.

•Pre-Existing Disease Cover Plans:

It offers covers against disease that policyholder had before buying health policy. Pre-Existing Disease Cover Plans offers
cover against pre-existing disease e.g. diabetes, kidney failure and many more. After Waiting period of 2 to 4 years it
gives all covers to insurer.

•Senior Citizen Health Insurance:

As name suggest These kind of health insurance plans are for older people in the family. It provide covers and protection
from health issues during old age. According to IRDAI guidelines, each insurer should provide cover up to the age of 65
years.
•Maternity Health Insurance:

Maternity health insurance ensures coverage for maternity and other additional expenses. It takes care of both pre
and post natal care, baby delivery (either normal or caesarean). Like other insurance, the maternity insurance
provider have wide range of network hospitals and takes care of ambulance expense.

These services are supervised by the Maternity Benefit Act. The Maternity Benefit Act applies to women who do
not work in an establishment covered by the ESI but who are employed in factories, mines, circuses, plantations,
shops or other establishments employing at least 10 persons. Also covered are women working in an
establishment covered by the ESI, but whose salary exceeds the ceiling of subjection.

Since 2010, the Indira Gandhi Matritva Sahyog Yojana (IGMSY) program, run by the Ministry of Women and Child
Development, has been set up in some districts (52 in 2017). This program is intended for pregnant women aged
19 or over, during their first 2 completed pregnancies (viable child). The benefit consists of a total amount
of ₹6,000 paid in 3 installments, subject to having performed the obligatory medical examinations for the mother
and the child:

• At the end of 2nd trimester of pregnancy.

• At birth.
• To 6th months of child.
•Hospital daily cash benefit plans:
Daily cash benefits is a defined benefit policy that pays a defined sum of money for every day of hospitalization.
The payments for a defined number of days in the policy year and may be subject to a deductible of few days.

•Critical illness plans:

These are benefit based policies which pay a lumpsum (fixed) benefit amount on diagnosis of covered critical
illness and medical procedures. These illness are generally specific and high severity and low frequency in
nature that cost high when compared to day to day medical / treatment need. e.g. heart attack, cancer, stroke
etc. Now some insurers have come up with option of staggered payment of claims in combination to upfront
lumpsum payment.

•Pro active plans:

Some companies offer Pro active living programs. These are designed keeping in mind the Indian market and
provide assistance based on medical, behavioural and lifestyle factors associated with chronic conditions. These
services aim to help customers understand and manage their health better.

•Disease specific special plans:

Some companies offer specially designed disease specific plans like Dengue Care. These are designed keeping in mind the
growing occurrence of viral diseases like Dengue in India which has become a cause of concern and thus provide
assistance based on medical needs, behavioural and lifestyle factors associated with such conditions. These plans aim to
help customers manage their unexpected health expenses better and at a very minimal cost.
 ADVANTAGES OF HEALTH INSURANCE
1. Health Insurance Keeps You Financially Protected

As mentioned above, the biggest benefit of purchasing health insurance is that it prevents erosion of your long-term
savings. You might be saving and investing for goals such as buying a property or child's education, but you or someone in
your family suffering from a medical emergency can require you to liquidate your assets.

If you are still unable to manage the expenses, you might also go ahead and borrow money from family, friends, or take a
loan. All of these things can put a huge dent on your current financial health as well as long-term objectives. Having
health insurance can help you avoid such outcomes due to the rising cost of quality healthcare.

2. Availability of Options

Gone are the days when insurers only used to offer basic health insurance plans. Modern insurance providers now offer a
wide range of health insurance policies. For instance, most insurers now offer individual policy and family floater plans.
You get to protect yourself with an individual plan, but with a family floater plan, you can insure the health of your entire
family.

Apart from these two popular options, you can also find other types of health plans like ULHP (Unit Linked Health
Insurance), critical illness plan, group health insurance, personal accident plan, and hospital cash benefit plan. The
availability of so many options ensures that you can select a policy that best meets your requirements.
3. Cashless Hospitalization 

One of the biggest benefits of health insurance is cashless claims. Most top insurers nowadays have an extensive list of
network hospitals all over the country. In case if you are suffering from a health problem and get admitted to one of the
network hospitals, you’ll mostly be able to take advantage of cashless hospitalisation.

This facility eliminates the traditional claim reimbursement process where you were first required to clear the hospital dues
and then get it reimbursed from the insurer. With cashless treatment, the insurer will directly pay your medical bills to the
hospital. Thus, you will not be required to bear the high treatment costs from your pockets. In case if you are admitted to a
non-network hospital, you will be able to use the reimbursement claim facility here.

4. No Claim Bonus (NCB)

Health insurance plans also come with a bonus element known as NCB. Health plans are generally renewed every year by
paying the insurance premium. But if you do not file any claim for the entire year, you will be entitled to receive NCB. This
NCB benefit is also available with vehicle insurance plans. However, there is a major difference between NCB of vehicle
insurance and health insurance.

With motor insurance, the NCB reduces the annual premium. But with health insurance, the NCB provides you with a
higher sum assured at the same premium amount. So, if the coverage of your health insurance plan is Rs. 5 lakhs and you
do not file any claim in a year, the coverage will be increased to Rs. 5.5 lakhs (10% of coverage) in the next year without any
increment in the premium amount.
5.Availability of Add-Ons or Riders

There are also many different types of add-ons available with health insurance policies. While the add-ons slightly increase the
policy premium, they help in significantly enhancing the scope of the plan. Even if you are purchasing a basic health insurance
policy, such add-ons can make your health insurance more beneficial.

For instance, a lot of health insurance plans exclude several critical illnesses such as cancer or heart diseases or do not cover
treatments arising from an accident. You can go ahead and purchase a critical illness or accident cover add-on to make sure
that your policy covers such exclusions as well.

6. Tax Benefit

A large number of people in India end up purchasing health insurance just because of the tax benefit it offers. While the tax
benefit shouldn't be the reason why you invest in health insurance, it still is a significant advantage. Under Section 80D of the
IT Act, an individual below 60 years can claim a tax deduction of up to Rs. 25,000 for the premiums paid against a health
insurance policy. If you are above 60 years, the deduction limit is up to Rs. 50,000.

If you have also purchased health insurance for your below 60 years parent/s, there is an additional tax deduction of Rs.
25,000. In case if the age of your parent/s is above 60 years, the deduction available is up to Rs. 50,000. So, if you are below 60
years and have purchased a health policy for yourself, as well as, for your above 60 years parent/s, the total tax deduction you
can claim in a financial year is up to Rs. 75,000.
 DISADVANTAGES OF HEALTH INSURANCE
1. Premium Increases with Age

Talking about the cons, one of the most important of them is the link between health insurance premiums and age. Your age
plays a crucial role in deciding the premium of your policy. There can be a significant difference in the premium amount when
you purchase a health policy when you are 30 years old and when you buy one after crossing 50 years.

In fact, it can also be challenging to find a health insurance policy once you cross 60 years. As the chances of you suffering from a
health condition increase considerably with age, the insurers make up for the increased risk by charging a higher premium. This
is the reason why it is said that you should prefer purchasing health insurance when you are still young.

2. Waiting Period for Existing Health Problems

Most of the health insurance plans also have a waiting period of up to 2-3 years for pre-existing diseases. If you are already
suffering from a health condition such as blood pressure, diabetes, thyroid, etc. at the time of purchasing a policy, any medical
costs arising from these conditions will not be covered until the waiting period is over.

This is one of the biggest disadvantages of health insurance policies as it requires you to bear the healthcare expenses even
when you have purchased health insurance. This is another reason why you should purchase a health insurance policy when you
are young and healthy. However, there are now insurance plans that come with a lower waiting period.
3. Co-Pay Clause

In order to prevent false claim filing, many of the insurance policies also have a co-pay or deductible
clause. If the policy you have purchased has a co-pay clause, you will be required to share your medical
expenses with your insurance provider. The co-pay is generally defined in percentage of the total
healthcare bill.

For instance, if your policy has a co-pay clause of 20%, you will be required to pay 20% of your hospital
bill, and your insurer will pay the rest. Such clauses are now generally found in cheap health plans that
attract people with their low premiums. Before purchasing a policy, you should always thoroughly check
the policy document to check the inclusions, exclusions, and other clauses.
  Data analysis

Table 1 shows that health insurance premium increased from Rs.1910 crores in 2006–2007 to Rs. 33011 crores in 2018–
2019. But claims incurred together with commission and management expenses have grown from Rs. 3349 crores to Rs.
40076 crores during the same period. So the claims and management expenses incurred together is more than the health
insurance premium earned in all the years of our study thereby leading to underwriting loss.

Table 1.
Data showing health insurance premium earned and claims and management expenses paid

Total claims and

Health insurance Commission and commission and
premium earned (Rs. Claims incurred (Rs. management exps management exps
Year Crs.) Crs.) incurred (Rs. Crs.) incurred (Rs.Crs.)
2006–2007 1909.59 2687.49 662 3349
2007–2008 3224.27 3422.43 1139 4561
2008–2009 5017.47 5256.19 1849 7105
2009–2010 6351.82 6857.31 2362 9219
2010–2011 8783.61 8546.18 3350 11896
2011–2012 9660.52 9013.42 3239 12252
2012–2013 11413.76 10834.29 3630 14464

2013–2014 14373.7 14007.22 4167 18174

2014–2015 17260.69 17405.79 5343 22749

2015–2016 20456.57 20900.18 6629 27529

2016–2017 24709.75 26088.59 7059 33148

2017–2018 27875.24 26247.22 8329 34576

2018–2019 33010.89 30027.26 10049 40076

shows that health insurance premium increased from Rs.1910 crores in 2006–2007 to Rs. 33011
crores in 2018–2019. But claims incurred together with commission and management expenses
have grown from Rs. 3349 crores to Rs. 40076 crores during the same period. So the claims and
management expenses incurred together is more than the health insurance premium earned in
all the years of our study thereby leading to underwriting loss.

Claim incurred shown above is the outcome of the risk covered against which premium is
received and commission and management expenses are incurred to obtain contract of
insurance. Both these expenses are important for insurance companies to generate new business
as stiff competition exists in this sector since it was opened up in the year 2000.
FIGURE
 FIGURE.1 DISCRIPTION

Figure depicts the relationship between health insurance premium earned and claims and management
expenses incurred by the insurance companies of the health insurance sector for the period 2006–2007 to
2018–2019.

Bar chart between premiums earned and claims and management expenses incurred show that claims and
management expenses together is higher than premium earned in all the years of the study thereby leading
to losses. Claims, commission and management expenses are important factors leading to the sale of
insurance policies thereby earning revenue for the insurance companies in the form of premium. But proper
management of claims and commission and management expenses will help this sector to improve its
performance.
Table 2.provides insight into the performance of health insurance sector in India. The growth of health
insurance in India has been from Rs.1909 crores for the financial year 2006–2007 to Rs. 33011crores for the
financial year 2018–2019. The growth percentage is 1629% i.e. growing at an average rate of 135% per annum.
Compounded Annual Growth Rate (CAGR) is working out to be 27%.

From the same table, it can be inferred that health insurance sector is making underwriting loss in all the
financial years. There is no specific trend can be seen, it has increased in some years and decreased in some
other years. Here underwriting loss is calculated by deducting claims and commission and management
expenses incurred from health insurance premium earned during these periods.

With every unit of increase in premium income the claims incurred together with commission and management
expenses paid increased more than a unit. Thereby up setting the bottom line. So instead of earning profit due
to better business through higher premium income, it has incurred losses.

Underwriting principles needs to be streamlined so that proper scrutiny of each policy is carried out so that
performance of this sector improves.
 Table 2.
Data on performance of health insurance sector in India

Net earned premium of Commission and

health insurance (Rs. Claims incurred (Rs. management exps Underwriting profit/loss
Year Crs.) Crs.) incurred (Rs. Crs.) (Rs. Crs.)
2006–2007 1909.59 2687.49 662 −1440
2007–2008 3224.27 3422.43 1139 −1337
2008–2009 5017.47 5256.19 1849 −2088
2009–2010 6351.82 6857.31 2362 −2867
2010–2011 8783.61 8546.18 3350 −3113
2011–2012 9660.52 9013.42 3239 −2592
2012–2013 11413.76 10834.29 3630 −3051
2013–2014 14373.7 14007.22 4167 −3801
2014–2015 17260.69 17405.79 5343 −5488
2015–2016 20456.57 20900.18 6629 −7073
2016–2017 24709.75 26088.59 7059 −8438
2017–2018 27875.24 26247.22 8329 −6701
2018–2019 33010.89 3
 FIGURE 2. DESCRIPTION

It is seen from that there is stiff rise in premium earned over the years but claims and
commission and management expenses incurred have also grown equally and together
surpassed earned premium. So the net impact resulted in loss to this sector which can also
be seen in the figure. It is also seen that loss is increasing over the years. So, increase in
earnings of revenue in the form of premium is leading to increase in losses in this sector
which is normally not seen in any other sectors.

But a time will come when commission and management expenses will stabilize through
market forces to minimize underwriting losses. On the other hand, it will also require
proper management of claims so that health insurance sector can come of this unprofitable
period.
BENEFITS OF FAMILY HEALTH INSURANCE
 TYPES OF HEALTH INSURANCE

1 FAMILY FLOATER HEALTH INSURANCE –

ALL THE FAMILY MEMBERS (YOU,YOUR SPOUSE, CHILDERNS AND PARENTS) IN A SINGAL
POLICY.

2 CRITICLAL ILLNESS HEALTH PLAN –

PROVIDES FINANCIAL COVERAGE TO THE INSURED IN CASE HE/SHE IS DIAGNOSED WITH
A LISTED CRITICAL ILLNESS/ DISEASE

3 TOP – UP HEALTH PLAN –

PROVIDE EXTRA COVERAGE IF YOUR EXISITING HEALTH PLAN IS NOT ENOUGH TO MEET THE MEDICAL

BILLS
 COMPANY AND BENEFITES

CARE HEALTH

•19000+ CashlessHealthcare Providers

•Coverage againstCOVID-19
•95.2% ClaimSettlement Ratio*
•Tax BenefitsUnder Section 80D
•30 Lacs+Claims Settled^
Care Health Insurance Limited is part of the Religare Group and a direct subsidiary of Religare Enterprises Limited.
Kedaara Capital is a co-promoter of the company. Care Health Insurance is an Indian health insurance company
established in July 2012.

PRODUCTS OF CARE HEALTH

•CARE SUPREME
•Health Insurance With Unlimited Coverage Up To Sum Insured
•CARE ADVANTAGE
•Health Insurance Plan With 1 Crore Cover
•CARE CLASSIC
•A Zone-Based Health Insurance For Families Across India
•CARE PLUS - YOUTH HEALTH INSURANCE PLAN
•Highly Flexible And Cost-Effective Health Plan
•CARE PLUS - THE COMPLETE HEALTH INSURANCE PLAN
•Health Insurance With No Upper Age Limit
•CARE FOR 45+
•A Comprehensive Health Insurance Plan That Supports You In Your Late 40s
•CARE FREEDOM
•Health Insurance Without Pre-Policy Check-Up
•CARE SENIOR
•Senior Citizen Health Insurance Plan Above 61 Years
•CARE HEART
•Health Insurance Plan Covering Pre-Existing Heart Ailments
•SENIOR HEALTH ADVANTAGE
•Highly Affordable Plan With Comprehensive Benefits
•CARE
•Health Insurance Plan For Family & Individual
•ENHANCE
•Super Top Up Health Insurance Plan
•JOY
•Maternity Insurance Plan With Baby Cover
 NIVA BUPA

•Hospitalisation cover against COVID-19

•Discount on premium up to 7.5% when you buy online
•30-minute cashless claim processing
•Pan-India cashless network of 7600+ hospitals
•Max Bupa is now Niva Bupa Health Insurance

•Niva Bupa Health Insurance Company Limited is an Indian health insurance company, founded in
2008. It is headquartered in New Delhi, India. It started as a joint venture between Max India Limited
and Bupa, the UK-based international healthcare group
Niva Bupa Health Insurance (formerly known as Max Bupa Health Insurance)  is one of the most trusted standalone
health insurance partners. We have curated affordable and comprehensive healthcare policies catering to the different
needs of our consumers.

We aim to give every Indian the confidence to access best healthcare by providing health insurance plans as per your
needs. Our innovative and comprehensive health policies have made us one of the leading health insurance and
medical insurance company in India.

PRODCUT OF NIVA BUPA

*Reassure
Our feature packed, best selling comperehensive health insurance plan
*Senior First
A health insurance plan made for senior citizens
*Health Recharge
A Top-up plan for your loved ones protection
*Money Saver
Combination of base and top-up pian to offer protection for your family’s health
*Health Premia
Our top selling plan for high networth individuals
 MANIPALCIGNA HEALTH INSURANCE

It’s not just Health Insurance, it’s HealthCare insurance!

It covers expenses beyond hospitalization. Doctor consultations, laboratory test and pharmacy make up for significant portion
of our healthcare expenses. The Wellness feature fetches you rewards based on the number of steps taken per day towards
better health maintenance i.e. premium savings based on the steps you have walked per day.

Covers non-medical expenses

No surprise bills in your hospitalization ensuring 100% of claim. ProHealth Prime takes care of your non-medical expenses.
Syringes, hand gloves, even registration charges and so many other things which are neither medicines, nor consultancy, nor
diagnostics and yet the expenses which form significant part of hospitalization charges.
Switch it off when you don’t need it

For the first time ever, you can switch off your cover when you won’t be needing it, like while abroad, for a month & get a
discount on the next premium.

Choice of Any Room category

ProHealth Prime gives you complete peace of mind by allowing you to opt for “Any room” category, suite or above, as you
deem fit.

Unlimited Restoration, for Real !!!

Your ProHealth Prime coverage restores to 100% of Sum Insured unlimited times if at any point, you are short of coverage.
And that’s for both related and unrelated illnesses / injuries. Applicable from 2nd claim onwards.

Annual Health Check up

From 1st year onwards for all the adults insured to take the utmost care of your health, not just in illness but in wellness
too.
And yes, Pre Existing Diseases ARE Covered

There is only a 90-day waiting period for claiming the expenses in case of hospitalization for illnesses such as asthma,
diabetes, hypertension, dyslipidemia, & obesity related conditions. Other PED’s as per mentioned in Annexure.

1 Year Premium Waiver

When you go through the saddest moments and need the financial support, we ensure insurance premium is not the burden,
to you and your family. If diagnosed with any of the listed Critical Illnesses or in an unfortunate event of Accidental Death,
we waive off one year renewal policy premium so you and your family stay protected throughout.
 SBI GENREAL

• Coverage Against Covid’19

•   Cashless Treatments*
•    Choose Customize Riders
•    Tax Benefit u/s 80D
•    IRDA Approved Plans

•1) PREAMBLE - This Policy is a contract of insurance issued by SBI General (hereinafter called the ‘Company’) to the proposer
mentioned in the schedule (hereinafter called the ‘Insured’) to cover the person(s) named in the schedule (hereinafter called the "Insured
Persons). The policy is based on the statements and declaration provided in the proposal Form by the proposer and is subject to receipt
of the requisite premium.

• 2) OPERATIVECLAUSE -If during the policy period one or more Insured Person (s) is required to be hospitalized for
treatment of an illness or Injury at a Hospital/ Day Care Centre, following Medical Advice of a duly qualified Medical
Practitioner, the Company shall indemnify Medically necessary, expenses towards the Coverage mentioned in the policy
schedule. Provided further that
, any amount payable under the policy shall be subject to the terms of coverage (including any co-pay, sub limits),
exclusions, conditions and definitions contained herein. Maximum liability of the Company under all such Claims
during each Policy Year shall be the Sum Insured (Individual or Floater) opted and Cumulative Bonus (if any)
specified in the Schedule.

3) DEFINITIONS

The terms defined below and at other junctures in the Policy have the meanings ascribed to them wherever they appear in this
Policy and, where, the context so requires, references to the singular include references to the plural; references to the male
includes the female and references to any statutory enactment includes subsequent changes to the same.

3.1. Accident means a sudden, unforeseen and involuntary event caused by external, visible and violent means.
3.2. Age means age of the Insured person on last birthday as on date of commencement of the Policy.
3.3. Any One illness means continuous period of illness and it includes relapse within forty-five days from the date or last
consultation with the hospital where treatment has been taken.
3.4. AYUSH Treatment refers to hospitalisation treatments given under Ayurveda, Yoga and Naturopathy, Unani, Siddha and
Homeopathy systems.
3.5. An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions
are carried out by AYUSH Medical Practitioner(s) comprising of any
a) Central or State Government AYUSH Hospital or
b) Teaching hospital attached to AYUSH College recognized by the Central Government/Central Council of Indian
Medicine/Central Council for Homeopathy; Or
c) AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized system of medicine,
registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH
Medical Practitioner and must comply with all the following criterion:
d) Having at least 5 in-patient beds;
e) Having qualified AYUSH Medical Practitioner in charge round the clocks; iii. Having dedicated AYUSH therapy sections as
required and/or has equipped operation theatre where surgical procedures are to be carried out,
f) Maintaining daily records of the patients and making them accessible to the insurance company's authorized
representative.
g) AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre (PHC), Dispensary,
Clinic, Polyclinic or any such health centre which is registered with the local authorities, wherever applicable and having
facilities for carrying out treatment procedures and medical or surgical/para-surgical interventions or both under the
supervision of registered AYUSH Medical Practitioner (s) on day care basis without in-patient services and must comply
with all the following criterion: i.
h) Having qualified registered AYUSH Medical Practitioner(s) in charge; ii.
i) Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures
are to be carried out; iii.
j) Maintaining daily records of the patients and making them accessible to the insurance company’s authorized
representative.
k) Break in Policy means the period of gap that occurs at the end of the existing policy term, when the premium due for
renewal on a given policy is not paid on or before the premium renewal date or within 30 days thereof
 L) Cashless Facility means a facility extended by the insurer to the insured where the payments, of the costs of
treatment undergone by the insured person in accordance with the Policy terms and conditions. are directly made to
the network provider by the insurer to the extent Pre-authorisation is approved.
M) Condition Precedent means a Policy term or condition upon which the Company's liability under the Policy is
conditional upon.
N) Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to
form, structure or position.
a) Internal Congenital Anomaly Congenital anomaly which is not in the visible and accessible parts of the body.
b) External Congenital Anomaly Congenital anomaly which is in the visible and accessible parts of the body.
c) Co-payment means a cost sharing requirement under a health insurance policy that provides that the
policyholder/insured will bear a specified percentage of the admissible claims amount. A copayment does not reduce
the Sum Insured.
O) . Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated
increase in premium.
P) Day Care Centre means any institution established for day care treatment of disease injuries or medical setup within
a hospital and which has been registered with the local authorities wherever applicable, and is under the supervision of
a registered and qualified medical practitioner AND must comply with all minimum criteria as under:
i. has qualified nursing staff under its employment;
ii. has qualified medical practitioner (S) in charge;
iii. has a fully equipped operation theatre of its own where surgical procedures are carried out
iv. maintains daily records of patients and shall make these accessible to the Company’s authorized personnel.
Q) Day Care Treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under general or local anaesthesia in a hospital/day care centre in less than twentyfour hours because of
technological advancement, and ii. which would have otherwise required a hospitalisation of more than twenty-four
hours. Treatment normally taken on an out-patient basis is not included in the scope of this definition.
ii. Dental treatment means a treatment carried out by a dental practitioner including examinations, filings (Where
appropriate), crowns, extractions and surgery.
iii. Disclosure to information norm: The policy shall be void and all premium paid thereon shall be forfeited to the
Company in the event of misrepresentation, mis-description or non-disclosure of any material fact.
iv. Emergeney Care: Emergency care means management for an illness or injury which results in symptoms which occur
suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long
term impairment of the insured person’s health.
v. Family means, the Family that consists of the proposer and any one or more of the family members as mentioned
below i. legally wedded spouse