Max Bupa Health Insurance Company LimitedCorporate Office: 2nd Floor, Salcon Ras Vilas, D-1, District Centre, Saket, New Delhi - 110 017

Registered Office: Max House, 1 Dr. Jha Marg, Okhla, New Delhi - 110 020

LITERATURE

Employee First Health Insurance Plan

SALESPROSPECTUS

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Phone: 1800 3010 3333 (Toll Free) or 3300 3333

Disclaimer:

Statutory Warning:

This is only a summary of the product features and is for reference purpose only. The details of benefits available

shall be as described in the Policy document, and will be subject to the policy terms, conditions and exclusions.

Please call our customer service if you require any further information or clarification.

Prohibition of rebates (under section 41 of Insurance Act 1938); no person shall allow or offer to allow either

directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of

any kind of risk relating to life or property, in India, any rebate of the whole or part of the commission payable or

any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy

accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or the

tables of the insurer. Any person making default in complying with the provision of this section shall be punished

with fine, which may extend to five hundred rupees.

If you wish to know more about Max Bupa’s Employee First Health Insurance

plan and/or would like a personal quote, speak to our specially trained sales

team or your local advisor. They’ll take time to fully understand your

requirements and help you to select the right plan for you.

Insurance is the subject matter of solicitation.

Web: www.maxbupa.com

1

EMPLOYEE FIRST HEALTH INSURANCE PLAN

Max India Limited: A reputation for excellence

Introducing Max Bupa Health Insurance Company Limited, a joint venture between Max India and Bupa, an

international health insurance company have joined hands to bring to India Max Bupa Health Insurance. We believe

in nurturing long-term relationship with our customers by providing the highest levels of quality in service.

Your employees’ Health comes first. Give them a Quality Health Insurance cover.

Our Parent Companies

Max Group brings expertise in insurance and

healthcare with a strong presence in Life Insurance

(through Max New York Life Insurance Company

Limited), Healthcare (through Max Healthcare Institute

Ltd.) and Clinical Research (through Max Neeman

Medical International Limited).

A Rs.7300 crore group, it has over 700 offices across

more than 400 locations in India as well as 4 million

customers, more than 20,000 employees and 80,000

agents, all focused on delivering customer satisfaction

(Source - www.maxindia.com).

Established in 1947 as the British United Provident

Association, Bupa today has over 10 million customers

in over 190 countries. (Source - www.bupa.com)

Bupa Group brings in a wealth of experience in serving

customers directly in health insurance across the

world. In addition to quality health insurance, Bupa

runs care homes for elderly people and the young

disabled, health assessments and health coaching and

workplace health programs for customers.

Bupa: 60 years of care

•The Health Insurance Company of the Year Award -

awarded at the U.K. Health Insurance Awards 2009

• Best International Private Medical Insurance Provider

2008 - awarded at the U.K. Health Insurance Awards

• Best Medical Insurer Company (2008, Bupa Arabia)

- awarded at the Jeddah Chamber of Commerce and

Industry Health Committee Awards

• Best Healthcare Provider of the Year - awarded at the

U.K. Corporate Adviser Awards 2009

• Best Individual Private Medical Insurance Provider

- awarded at the U.K Money Marketing Awards 2009

Bupa

• CII-Exim Bank Award for Business Excellence

awarded to Max New York Life in 2008

• CIO 100 Award for technology implementation

Recognition and awards

• Max New York Life was declared a ‘Superbrand’ by

Superbrands India in the 3rd edition of Consumer

Superbrands 2008

Max India:

Policy Design

Start a healty relationship

Employee First Health Insurance Plan is a corporate

group oriented health insurance cover which is simple

to buy and easy to understand. In addition to provid-

ing a core health insurance cover to suit your needs,

this plan helps you proactively take care of the health

of your employees and their dependants. We are here

to build a long term healthy relationship with your

organization and its employees.

We believe in empowering you to choose the cover

best suited for your group and that a healthy relation-

ship is built by understanding your needs, through a

continuous dialogue on what matters the most.

Advantages of signing up with Employee First Health

Insurance Plan:

We talk directly to you: You talk to us directly, not

through any third parties for claims. We will be there

for you when you need us. Because your employees

should concentrate on getting better or looking after

their relatives, rather than focusing on settlement of

claims.

• Cashless facility at quality hospitals: Your employees

can access our cashless facility at quality hospitals,

thanks to our relationship with them as part of our

partner network.

• No age restriction for enrollment: We provide cover

options for families across life stages – from new borns

to senior citizens of any age.

• High quality service:

1. 24/7 Healthline: Your employees can call us

anytime for help on Our 24/7 health line for easy

and friendly access to health advice when you

need it.

Employee First Health Insurance Plan can cover your

employee and her/his family under the same limit. The

base cover includes the employee, employee’s spouse

and two children. Additional children can be included

under the same limit, by paying additional premium.

Family under the Employee First Health Insurance Plan

includes the following:

1. Spouse (legally married)

2. Son

3. Daughter

Besides this you can also include the following

relations in the group cover, by paying additional

premium.

2. Managing our relationship: As a customer, you

can access your own page on the Max Bupa website

for reviewing your claims history, to access coverage

details by employee and manage policy audit

calendar. You will also get aggregated periodic

reports to better understand the medical needs of

your employees.

• Responsible enrollment: To build a relationship that

lasts a lifetime, We make all efforts to understand your

health profile during enrollment, so that when you

need us, we can provide speedy and efficient support.

• Policy carry forward: The employee has an option to

convert his group policy to an individual personal

cover, when he leaves his current employment.

• Tax saving: You may save tax under Section 36 (1)

of the Income Tax Act when you buy a Max Bupa

Health Insurance Policy (Tax benefits are subject to

changes in the tax laws, please consult your tax

advisor for more details).

32

Product Features and Benefits

8. Health Check-up: We will cover the cost of a health

check-up as per your plan eligibility as defined in

the Product Benefits Table. We will only cover

health check-ups arranged by Max Bupa through

our empanelled service providers.

4. Father

5. Mother

6. Father-in-law

7. Mother-in-law

• This policy covers persons of any age. There is no

maximum entry age for the Insured.

• There is no maximum cover ceasing age

in this policy.

• The tenure of the policy is one year.

The sum insured options range from Rs.1 lac to

Rs. 50 lacs depending on the plan you choose. The

details of the plans are available in the Product

Benefits Table.

Reasonable and Customary Charges mean the

charges for services or supplies, which are

standard charges for the specific provider and

consistent with the prevailing charges in the

geographical area for identical or similar services

among comparable providers, taking into account

the nature of the Illness/injury involved.

The policy covers Reasonable and Customary Expenses

incurred towards medical treatment taken during the

Policy Period for an Illness or an Accident. We cover

the following expenses:

1. In-patient Treatment: Medical Expenses for:

(i) Doctor’s fees, Diagnostics tests, Medicines,

drugs and consumables, Operation Theatre

charges, Intensive Care Unit, Intravenous fluids,

blood transfusion, injection administration charges

(ii) The cost of prosthetics and other devices or

equipment if implanted internally during a Surgical

Procedure.

2. Hospital Accommodation: Reasonable and

Customary charges for Hospital accommodation.

3. Pre and Post hospitalization Medical Expenses:

Medical Expenses incurred due to same Illness up to

30 days prior to admission and 60 days after an

Insured Person’s discharge from a Hospital.

4. Day-care Procedures: Medical Expenses for day

care procedures where such procedures are

undertaken by an Insured Person as an In-patient

in a Hospital for a continuous period of less than

24 hours. Any procedure undertaken at the

out-patient department of a Hospital will not be

covered. We cover all Day-care procedures, not just

a select few.

5. Domiciliary Treatment: Medical Expenses for

treatment taken at home if the treatment continues

for an uninterrupted period of 3 days and the

condition for which treatment is taken would

otherwise have necessitated as long as either (i) the

attending Doctor confirms that the Insured Person

could not be transferred to a Hospital or (ii) you the

insured employee satisfies us that a Hospital bed

was unavailable.

6. Organ Donor: Medical Expenses for an organ

donor’s treatment for harvesting of the organ

provided that the Insured Person has been medically

adviced to undergo an organ transplant and the

donation conforms to The Transplantation of

Human Organs Act 1994 and the organ is for the

use of the Insured Person.

We will not cover:

a) Pre-hospitalisation or post-hospitalisation Medical

Expenses or screening expenses of the donor or any

other medical expenses as a result of the harvesting

from the donor.

b) Costs directly or indirectly associated with the

acquisition of the donor’s organ.

7. Emergency Ambulance: Reasonable and Customary

ambulance expenses incurred to transfer the

Insured Person following an Emergency to the

nearest Hospital, if we accept the In-patient claim.

For Out of Network Hospitalisation our maximum

liability for ambulance expenses is limited to

Rs.2,000/- per event.

Sum Insured

The Employee First Health Insurance Plan allows you

to choose from a simple list of additional cover options

and waiver that you can purchase to customize the

cover according to your needs:

1. Maternity Benefits

• You can purchase maternity cover for all the group

members by paying additional premium. We will

cover Medical Expenses for the delivery of a child

subject to the following:

a) Maternity expenses shall be covered for female

Insured Person only for the delivery of a child,

either under sub clause below:

i) This benefit is available for the Primary Insured or

his spouse (if the spouse is named as an Insured

Person). This benefit may be claimed only twice

during the lifetime of the Insured Person.

b) Cover will be available under Maternity Benefit

only after 9 months of continuous coverage have

elapsed since the inception of the first Policy with

Max Bupa. However the group can purchase waiver

of this waiting period by paying additional

premium. This waiver is available for purchase only

to groups with more than 75 Employees.

c) Our maximum payout per pregnancy will be as

per the specified sub-limit as shown in the

Product Benefits Table.

d) We will cover Pre or Post Hospitalisation Medical

Expenses within the specified sub-limit. We will

cover Medical Expenses related to a Medically

Necessary termination of pregnancy subject to the

conditions mentioned above.

The following expenses are not covered under

Maternity Benefit:

a) Medical Expenses in respect of the harvesting and

storage of stem cells when carried out as a

preventive measure against possible future

Illnesses.

b) Medical Expenses for ectopic pregnancy are not

covered under Maternity Benefit. However, these

expenses are covered under the In-patient

benefit.

2. New Born Baby

If the pregnancy is covered by Max Bupa then, We will,

a) Cover Medical Expenses towards the medical

treatment of the Insured Person’s new born baby

while the Insured Person is Hospitalised as an

In-patient for delivery.

b) Cover the new born baby as an Insured Person

until the expiry date of the Policy without the

payment of any additional premium. The new born

baby will be covered within the existing limit of the

Insured without any limit enhancement.

c) Cover the Reasonable and Customary

vaccination expenses of the new born baby for the

vaccinations shown in Annexure I to this policy until

the new born baby completes one year. If the

policy ends before the new born baby has

completed one year, then, We will only cover such

vaccinations until the policy renewal, and after that

only if we have accepted the baby as an Insured

Person at the time of renewal and you have paid

the premium accordingly.

Additional Cover/Loadings

54

3. Family Floater Benefits

a) You can purchase coverage to include the group

members’ parents in the group policy as Insured

Person. The addition would not result in increase of

the total sum insured for the Family Floater Benefit.

b) You can purchase coverage to include the group

members’ parents-in-law in the group policy as

Insured Person. The addition would not result in

increase of the total sum insured for the Family

Floater Benefit.

Additional Services:

• Health Card: Health cards will be issued to each

group member.

• 24/7 Health-line: This facility has been put in place

to offer you access to health advice when you

need it.

• Relationship Doctor: We may assign at our

discretion, to attend to in-hospital claims

management for your employees.

• Reports and MIS: Standardized reporting for clients

irrespective of size of account.

• Online Servicing: You get a personalized page on

our website to manage your organizations’ health

insurance needs.

• Account Manager: Person to manage account

specific procedures and issues of the client.

• Health Camps: We may organize periodic health

camps at your location(s), customized to your

employee strength and profile.

• Direct Servicing: All claims are processed directly by

our own customer services team.

Claims for the following are not covered:

1. Pre-existing Conditions: Benefits will not be

available for Pre-existing Conditions until 48

months of continuous coverage have elapsed since

the inception of the first Policy with Us.

2. 30 Days Waiting Period: We will not cover any

treatment taken during the first 30 days since the

commencement of the Policy, unless the treatment

needed is a result of an Accident or Emergency.

This waiting period does not apply for any subse-

quent and continuous renewals of your policy.

The employer can choose to extend this

waiting period to 90 days to avail a discount on

schedule premium.

3. Specific Waiting Periods: For all Insured Persons the

conditions listed below will be subject to a waiting

period of 24 months from the date of commence-

ment of coverage for the Insured Person:

1. Stones in the urinary system

2. Stones in billiary system

3. Surgery on tonsils/ adenoids

4. Uternie Polyps

5. Any type of breast lumps

6. Treatment of Spondylosis/ Spondylitis -

any type

7. Inter Vertebral Disc Prolapse (IVDP) and such

other degenerative disorders

8. Cataract

9. BHP

10. Hysterectomy/ Myomectomy done due to

Menorrhagia/ fibroids

11. Fistula in ano

12. Fissure in ano

13. Piles

14. Hernia

15. Hydrocele

Waiting Periods and Exclusions16. Sinusitis

17. Knee/ hip joint replacement

18. CRF or end stage renal failure

19. Congenial cardiac ailments

20. Any type of Carcinoma/ sarcoma/

blood cancer

21. Osteo Arthritis of any joint

22. Gastric and duodenal Ulcers

23. Varicocele

24. Spermatocele

25. Dilatation and Curettage ( D&C)

26. Diabetic Nephropathy and Retinopathy

27. Mastoidectomy (operation to remove piece

of bone behind the ear)

28. Tympanoplasty (Surgery to repair tympanic

membrane i.e. eardrum)

29. Gout

30. Rheumatism

31. Varicose veins, Varicose ulcers

Waivers for Waiting Periods: The group can purchase

waiver of the following waiting period by paying

additional premium:

1. 30 Day waiting period

2. Specific waiting period

3. Pre-existing conditions waiting periods

However, these waivers are available for purchase only

to groups with more than 75 employees.

1. Co-pay: To help your employees take care of their

parents without making the costs unmanageable,

we have enabled you to cover their parents and

parent-in-laws. If any Insured Person is 60 years of

age or over on the date of commencement of the

current Policy Period, then Max Bupa will only pay

80% of claim under the policy made by that

Insured Person and the balance will be borne by

the Insured employee.

Co-pay discount options: The group can avail a

discount in premium calculation by opting for any

one of the below co-pay options:

a) 10% co-pay for all insured persons below the

age of 60 years along with the standard 20%

co-pay for insured persons of age 60 years or

more.

b) 20% co-pay for all insured persons in the group.

c) 30% co-pay for all insured persons in the group.

2. Permanent Exclusions: Addictive conditions and

disorders; Ageing and puberty; Artificial life mainte-

nance; Circumcision; Conflict and disaster;

Congenital conditions; Convalescence and rehabili-

tation; Cosmetic surgery; Dental/oral treatment;

Drugs and dressings for outpatient or take-home

use; Eyesight; Experimental treatment; Health

hydros, nature cure, Wellness clinics etc.; HIV and

AIDS; Hereditary conditions; Items of personal

comfort and convenience; Non-allopathic

treatment; Obesity; Out-patient Treatment;

Neurological and Psychiatric Conditions;

Self-inflicted injuries; Sexual problems and gender

issues; Sexually transmitted diseases; Sleep

disorders; Speech disorders; Treatment for develop-

mental problems; Treatment received outside India;

Unrecognised physician or facility; Unlawful

Activity.

For details of permanent exclusions please visit

www.maxbupa.com/exclusions

Cancellation by Us:

We may terminate this Policy by sending 30 days

prior written notice to your address shown in the

Schedule without refund of premium if in our

opinion:

i. You or any Insured Person or any person acting

on behalf of either has acted in a dishonest or

fraudulent manner, provided false or incorrect

information, or suppressed any important

information, under or in relation to this policy;

and/or

ii. Continuance of the policy poses a moral hazard;

Cancellation/Termination:

76

1. Renewal Premium: The renewal premium is

payable on the due as shown in the Schedule.

The rates used for premium calculation may

change on renewal (subject to IRDA approval). If

the Policy is not renewed within the due date

then we may issue a fresh policy subject to Max

Bupa underwriting criteria but (a) and any new

policy issued shall not benefit from any of the

continuity benefits (for example for Pre-existing

Conditions).

2. Maximum Age: There is no maximum cover

ceasing age in this Policy.

3. No underwriting on renewal: There will be no

underwriting on policy renewal for existing group

members. New members added at or between

renewals would undergo standard

underwriting rules. The first year underwriting

results will continue to apply and carry

forward for any group members that continue

in the policy group without break.

4. Disclosures on Continuity: If a Primary Insured

ceases to be your employee during the Policy

Period, then cover under the policy for that

Primary Insured and his Dependants will

immediately and automatically cease unless the

Primary Insured gives Us a written request prior to

or within 5 days of the date of cessation of

employment, to issue a new health insurance

policy to himself and his Dependents who were

named as Insured Persons in the Schedule for

cover up to his Sum Insured under the policy, on

payment of premium in full for the new policy. The

Primary Insured understands and agrees that:

(i) The issue of a new policy shall be subject to our

Renewal Information

Claims Procedure

underwriting requirements; as applicable from time

to time, and we may obtain additional information

before issuing a new policy.

(ii) We are not bound to continue all terms and

conditions of the present cover under the policy of

the Primary Insured and his Dependents under the

new policy, however for calculation of waiting

periods including for pre-existing conditions under

the new policy, the time spent by Primary Insured

and his Dependants under this Policy may be taken

into account, provided the new policy is taken

without any break from this Policy. Coverage under

the new policy shall be available only for the period

for which the premium has been received by us.

1. Cashless Hospitalisation Facility for Network

Hospitals: We will provide cashless hospitalisation

facility at Our network hospitals. We pre-authorise

all cashless In-patient and Day-care procedure, if

intimated to us 72 hours before hospitalisation

(within 48 hours after hospitalisation for emer-

gency). Under cashless hospitalisation, claims are

paid directly to the Network Hospital. In cases

where co-pay is applicable, the co-pay amount

will be collected by the provider from the customer.

Co-pay will be applied on the amount authorised to

the hospital. Additionally,it will be mentioned in the

Letter of Authorisation that co-pay will be

applicable on the final bill.

information that we believe may be required.

• For any medical treatment taken from an out of

Network Hospital, we will pay Reasonable and

Customary medical expenses. Delayed payments

shall attract interest as per applicable regulations.

3. Nomination Facility: The employee can, at the time

of joining or at any time before the expiry of the

Policy, make a nomination for the purpose of

payment of claims.

Disclosure

All cutomers’ personal information collected or

held by Max Bupa may be used by Max Bupa for

processing the claims and analysis related to

insurance/reinsurance business.

2. Out Of Network Hospitals and All Other Claims for

Reimbursement: We will reimburse expenses

incurred outside network hospitals. To claim

reimbursements for any Illness or Accident or

medical condition that requires Hospitalisation, the

Insured Person should provide us the documents

listed below, within 30 days of the Insured

Person’s discharge from Hospital.

• Duly filled claim form(s) supported by Investigation

test reports, Original bills, receipts and discharge

certificate/card from the Hospital/Doctor/Chemists

Doctor’s referral letter advising hospitalisation in

non-accident cases.

• Details of any other insurance policy that may

repond to the claim.

We might request for any other documents or

CO-PAYMENT SCENARIOS

CASHLESS CLAIM - SCENARIO 1

Sum Insured 2,00,000

Pre-Auth Requested Amount 1,00,000

Approved Amount (after deduction of 20% Co-pay) 80,000

Actual Final Bill Received 1,00,000

Copay @ 20% on Final Bill amount 20,000

Final Paid amount after deduction of Co-pay 80,000

Balanced Sum Insured 1,20,000

CASHLESS CLAIM – SCENARIO 2

Sum Insured 2,00,000

Pre-Auth Requested Amount 1,00,000

Approved Amount (after deduction of 20% Co-pay) 80,000

Actual Final Bill Received 90,000

Co-pay @ 20% on Final Bill amount 18,000

Final Paid amount after deduction of Co-pay 72,000

Balanced Sum Insured 1,28,000

98

($) Baseline cover includes a 48 month waiting period for pre-existing conditions & a 30 day no claims/waiting period from inception. (**) Emergency ambulance - Maximum of Rs. 2000/-per event for out of network. (*) A compulsory Co-pay of at least 20% applies to all insured older than 60 years. (***) A 9 month waiting period applies to maternity cover including all attached new born baby cover items. (@) Vaccinations would be covered till the next Policy anniversary after which the new born baby has to be included in the Policy for the coverage to continue. Note: Baseline cover benefits includes a maximum of 2 adult + 2 children on a family floater basis.

Overall Sum Insured (SI) Rupees

Baseline cover benefits ($), (*) In-patient treatment

Surgical operations, including pre and post-operative care

Nursing care, drugs and surgical dressings

Doctors’ feesOperation theatre charges and intensive care

Pathology, X-rays, diagnostic tests and therapies

Prosthetic implants

Hospital accommodation

Pre and post-hospitalisation expenses including doctor's consultation, diagnostics tests, medicines, drugs and consumables

All day care procedures

Health Check-up at time of renewal

Organ transplant when medically necessary

Other benefits

Emergency ambulance (**)

Domiciliary treatment

RupeesMaternity and child care benefits (***)

Maternity cover for up to 2 deliveries

New born baby cover

Vaccinations new born baby for the first year (@)

Additional Benefits that can be purchased for extra premium (availability as per annexure)

Extended family cover

Inclusion of parents as insured in the group Policy

Inclusion of parents-in-laws as insured in the group Policy

Inclusion of additional children beyond 2 children covered in the baseline coverWaivers available for purchase

9 month waiting period for Maternity benefit

30 day no claim/waiting period from Policy inception

24 month waiting period for Specific Exclusions

48 month waiting period for pre-existing conditions

Cover available with an optional co-pay of 10%, 20%, 30% for all members

Extension of 30 day waiting period to 90 days

Discounts available for customisation

Benefit Table - Employee First Health Insurance PlanOverall Sum Insured (SI)

1 lac 2 lacs 3 lacs 4 lacs 5 lacs 6 lacs 7 lacs 8 lacs 9 lacs 10 lacs 15 lacs 20 lacs 50 lacs

Single Private Room

Covered up to 15% of SI

Covered up to SI

Once in two years, tests as per annexure

Covered up to SI

Covered at actual costs in Network hospitals up to SI

Covered up to SI

Covered up to Rs. 30,000Covered up to SI

Covered up to SI and for specified list in annexure

Covered within the overall SI

Available to all groups with more than 75 employees

Available for all groups

Available for all groups

1 lac 2 lacs 3 lacs 4 lacs

Covered up to SI Covered up to SI

Covered at actual costs in Network hospitals up to SI Covered at actual costs in Network hospitals up to SI

Annual, tests as per annexure Annual, tests as per annexure

Single Private Room

Covered up to 20% of SI

Covered up to SI

Upgrade to next level, subject to availability

Covered up to SI Covered up to SI

Covered up to SI

Covered up to SI

Covered up toRs. 75,000

Covered up toRs. 1,00,000

Covered up toRs. 2,50,000

5 lacs 6 lacs 7 lacs 8 lacs 9 lacs 10 lacs 15 lacs 20 lacs 50 lacs

Covered up to Rs. 60,000 Covered up to Rs. 1,00,000Covered up to SI Covered up to SI

Covered up to SI and for specified list in annexure Covered up to SI and for specified list in annexure

Covered within the overall SICovered within the overall SI

Available to all groups with more than 75 employees

Available to all groups with more than 75 employees

Available for all groups Available for all groups

Available for all groups Available for all groups

Covered up toRs. 5,000

Covered up toRs. 10,000

Covered up toRs. 15,000

Covered up toRs. 20,000

Covered up toRs. 25,000

Covered up toRs. 30,000

Covered up toRs. 35,000

Covered up toRs. 40,000

Covered up toRs. 45,000

Covered up toRs. 50,000

Category Tests

Level 2 MER, RUA, FBS, T. CHOL. GGT

Level 3 MER, RUA, FBS, T. CHOL. GGT, HDL, TG, S. CREAT, SGOT, SGPT

Level 4 MER, RUA, FBS, T. CHOL. GGT, HDL, TG, S. CREAT, SGOT, SGPT, HbsAg, HbA1c, CBC, ECG

Level 5 MER, RUA, FBS, T. CHOL. GGT, HDL, TG, S. CREAT, SGOT, SGPT, HbsAg, HbA1c, CBC, TMT, HIV 1 AND 2

1110

5. Upon full assessment of medical facts, the

Underwriter, with possibly second opinion, has

discretion to decide whether the applicants

declared condition presents a future risk.

Three potential options will be determined by the

Underwriter.

• No Risk - accept application with no condition

exclusion(s).

• Potential Risk – accept application with special

conditions/ exclusion(s) (Pre-existing

exclusions).

• High Risk – decline.

The free cover limit would be offered to the

proposed insured as per the group size.

However, medical evaluation of the risk for the

Incremental Sum Insured, above the free cover

limit, would be the basis for determining no

risk, potential risk & high risk. Medical

evaluation will be done for Incremental Sum

Insured only.

Additionally the following rules will apply:

• In the event of the risk getting declined post

medical underwriting then the life would be

given a minimum cover equal to his/her Non

Medical Limit and higher cover (incremental

cover) would be declined.

• In the event of pre policy medicals getting

triggered then liability with Max Bupa is

equivalent to the Non Medical Limit until

medical underwriting is completed.

• The Sum Insured eligibility of the employee and

his/her dependents would be equal to the Non

Medical Limit or the Sum Insured approved by

the underwriter post medical underwriting.

• For all those members who are accepted post

medical underwriting, endorsement to the

policy would be done as and when final medical

underwriting decision is done

The underwriting decisions will be uploaded in

the lead management system and the core

system. The systems store the underwriting

data for each person insured. It captures the

pre existing disorders as ICD 10 codified

exclusions which have a waiting period of up to

four years as per the product definition.

6. All proposals accepted by Max Bupa are

internally processed and enrolled onto the Max

Bupa system, and premium payments are

cleared.

7. Every Insured Person receives a welcome kit

where the proposed risk has been accepted by

Max Bupa

8. The welcome kit will be delivered direct to the

Company.

4. An underwriting process will be followed for

every proposal form submitted, regardless of

the distribution channel.

• Medical underwriting would be done based

on Non Medical Limit (as mentioned in the

below grid). Non Medical Limit would be

dependent on the group size as mentioned

below.

• For group upto 20 employees, medical

underwriting would be done as per the

below mentioned Medical Tests Grid. For all

other groups, medical underwriting to be

done only on the incremental Sum Insured

over the Non Medical Limit.

• Pre policy medicals would be required for all

the members wherein Sum Insured

breaches the Non Medical Limit.

• Pre policy medical tests (as per the below

mentioned grid) to be triggered only on the

incremental Sum Insured over Non Medical

Limit.

How to buy a Max Bupa Policy

1. The Max Bupa Policy is sold, through all the

direct and indirect channels such as, Agency,

Corporate Agency, Direct Sales Team and Tele

sales.

2. Every Insured Person will be assigned a unique

customer identification number on the Max

Bupa system.

3. A Max Bupa proposal form is completed. The

Customer will be required to provide:

• Insured’s name, date of birth, designation

and address, as necessary.

• As above for all dependants to be covered by

the policy.

• Any existing health insurance Policy details

and claims history, if applicable.

• Selection of Employee First Health Insurance

Plan sum insured, waivers and additional

cover.

• Disclosure of any pre-existing medical

conditions with details.

• Medical history report for applicant and

dependants, if necessary.

• Signature and date on application, wherever

applicable.

• Premium payment collected and receipted.

Note: Medicals to be triggered based on the incremental Sum Insured over Non Medical Limit.

Medical Tests Grid:

Age(completed birthday)

Upto 50 years

51 - 55 years

> 55 years

Upto 5 lacs

Level 2

Level 2

Level 3

5.01 - 10 lacs

Level 2

Level 3

Level 4

>10 lacs

Level 3

Level 4

Level 5

Incremental Sum Insured (INR)

Non Medical Limit (INR)

0

5 lac

5 lac

7 lac

10 lac

10 lac

Number of Employees

0-20

21-50

51-100

101-200

201-500

500+

NOTES: NOTES: