Optima Senior Ready-Reckoner - Apollo Munich...For Internal Circulation And Training Purposes 3 Copyright by Apollo Munich Health Insurance Company Limited. All Rights Reserved. 1

For Internal Circulation And Training Purposes

1 Copyright by Apollo Munich Health Insurance Company Limited. All Rights Reserved.

Optima Senior

Ready-Reckoner



Index

Index 2

1 Sum Insured & Variants 3

2 Insurability 3

2.1 Insurable persons .......................................................................................... 3

2.2 Entry Age .................................................................................................... 3

2.3 Individual policies ......................................................................................... 3

3 Checklist for Proposal Form 3

3.1 Basic checks ................................................................................................ 3

3.2 Proposal form .............................................................................................. 3

4 Checklist for Additional Documents 5

4.1 Age Proof ................................................................................................... 5

4.2 Address Proof .............................................................................................. 5

4.3 Proposer not getting covered himself or covering self alone ...................................... 6

4.4 Financial Underwriting: .................................................................................. 6

5 Special Cases 6

6 Declined Conditions List 7

7 Premium payment 7

7.1 Cheque Dishonour ......................................................................................... 7

8 Pre Policy Check Up 8

9 Risk Start Date Logic 9

10 Portability 11

11 Renewals 12

12 Endorsements 13

13 Glossary 14

14 Claim Procedure 15



1 Sum Insured & Variants

1) Optima Senior is available on a individual sum insured basis with maximum 2 insured members per policy

2) The policy will be issued for a period 1/2 year.

3) Sum insured available Rs. 200,000; 300,000 & 500,000

4) Same sum insured must be opted for both the insureds (Self and Spouse if self proposed/ Father and Mother

if proposed by son/daughter).

2 Insurability

2.1 Insurable persons

2.2 Entry Age

1) Policy Holder: Minimum 61 years and above

2) Adult Dependent: Minimum 61 years and above

3) Cover Ceasing Age: Nil

4) Premium is calculated on completed years of age as on the last birthday

2.3 Individual policies

The maximum permissible members cannot exceed 2 insured’s per policy. PH (Policy holder) would either be the proposer himself if getting insured in the policy. AD (Adult dependent) can be spouse, father or mother of the proposer.

3 Checklist for Proposal Form

3.1 Basic checks

i) All questions must be answered as per advice in the proposal form.

ii) Each question in section 7A, 7B, 7C and 7E (Medical declaration) must be answered individually for all

insureds. Section 7C should be replied to in all cases if any adverse medical declaration noted in section

7A/7B, else same may be replied as No or N/A, but blank response would not be acceptable. Section 7D

alone is acceptable if blank.

iii) Any overwriting or corrections must be counter signed by the proposer. Use of whitener is not allowed.

iv) N/A to be captured only for sections where the question is not relevant to the gender (Q No 13 of Sec 7A

and Q No 19 & 20 of Sec 7B).

v) Each page of all of the documents submitted needs to be checked thoroughly.

3.2 Proposal form

i. Name and address:

a) Name and address should be correctly filled in with 6 digit PIN code.

Self Father

Spouse Mother



b) Either mobile or Telephone number should be mentioned. Mobile number should contain 10 digits,

and landline number should have correct STD code of the city as prefix & contain correct number of

digits. Total digits in the landline number should be 11 including the STD code. (E.g. Gurgaon

landline number containing 7 digits, or Metro number with 8 digits).

c) E mail address should be provided (if any).

d) Salutations:

Age Title Gender

61 and above Mr Male

61 and above

For Divorcee/Single/Widow Ms Female

For Married Mrs Female

ii. Nationality: Nationality should be mentioned. If nationality mentioned is other than Indian, refer

guidelines below.

a) Those currently working or settled in India are eligible for the cover e.g. NRI/PIO who have

returned back to India and gainfully employed, or Foreign national who has taken up Indian

assignment, etc.

b) Coverage may be extended to people based outside India as well, subject to prior medical

underwriting approval and proposal form been signed in India by the proposer only.

c) Those working in India for a continuous period of 6 months or have valid Visa for a period

corresponding to requested policy period may be allowed subject to the following

a) Copy of all pages of passport showing Visa and recent Entry/Exit stamps from India

b) Current VISA validity of at least 6 months duration

iii. Marital status: If divorced/separated and proposed insured is female, family details form must be

submitted. Family details form would not be required in case of widow.

iv. Income details: For this product annual income of the proposer would not be a mandatory field where

self/spouse are proposing for themselves,Incase son or daughter are proposing for their parents annual

income field should be mandatorily filled.

v. Occupation: Profession needs to be ticked on proposal, and details should be mentioned, regarding exact

occupation in case if option ticked as ‘Others’, exact nature of duties in case if option ticked as ‘Salaried’

and exact line of business in case if option ticked as ‘Self employed’ against each insured for accurate

occupation classification. Even health insurance is not offered to occupation class IV (AC4) occupations.

vi. Benefit section: Policy Period to be either ticked 1 Year/ 2 Year.

vii. Height & weight, DOB (Date of birth), Occupation and Gender details: Height & weight, DOB, Occupation

and Gender information of all insured should be mentioned clearly in the respective column.

viii. Relationship: Relationship of Insured to Proposer should be mentioned in the respective column.

Allowable relationships include Self, Spouse or Father, Mother where Son or Daughter are proposing for

their parents.

ix. Existing insurance details & portability: Previous insurance policy No, Name of the insurer, Insurance

coverage period, sum insured and claims details (if any) should be mentioned in the column provided. If

previous insurance policy details are filled in, then question related to desire for continuity benefits must

be answered as Yes/No.

x. Nominee details: If provided, Name, Address and Relationship of nominee with proposer needs to be

mentioned in the column provided. The nominee mentioned in the proposal form must be an immediate

relative of the primary proposer only (Father, Mother, Spouse, Brother, Sister, Son or Daughter). For

other proposed insured (other than the proposer) the nominee shall be the proposer him/herself.

xi. Medical questionnaire: All questions against each insured to be answered individually as Yes/No (Y/N),

except in case of female life question (Q No 13 of Sec 7A or Q No 19 & 20 of Sec 7B). For all answers as

Yes/Y, details needs to be provided in relevant column of Sec 7C against each insured individually.

Relevant documents (if any) may be attached for faster processing of cases, avoiding want of calling for

additional information post underwriting.



xii. Personal habits: Tobacco, Pan masala and Alcohol consumption habits of all insured along with quantities

& frequency (if replied as Yes/Y), should be mentioned individually.

xiii. All declarations: All declarations must be signed by the proposer. If signed in vernacular language or

thumb impression, vernacular declaration needs to be completed with witness name & signature.

xiv. If payor and proposer are the same, check the signatures on cheque & application form if payment mode

is cheque. If not matching, please get declaration from the proposer on usage of different signatures for

the insurance application and cheque, if not provided in additional information column. This declaration

must carry both the signatures used.

xv. Premium payment (amount, mode and payor details): Payment details viz Instrument details, Name of

the payor, Bank details, Date and Amount to be mentioned in the column.

xvi. All cases would be subject to PPC and if there is change in age band (Premium perspective), customer

should be pre-informed if requirement (Risk loading premium/Consent, whichever is later) is not

complied before DOB, revised premium shall be charged and/or PPC be called as per new age band.

4 Checklist for Additional Documents

4.1 Age Proof

Age proof if submitted needs to be verified for correctness of DOB mentioned on proposal i.e. DOB mentioned on

proposal and that on age proof submitted for the insured should match. When the age proof does not capture

DOB and captures age only, then age should match with the completed age as per DOB mentioned in the

application form.

Valid/Standard age proof:

i) School/College Certificate (Progress Report, Mark Sheet, Bonafied Certificate, Leaving Certificate,

Transfer Certificate etc)

ii) Passport

iii) Municipal Birth Certificate

iv) Employment Certificate showing DOB from Govt/public sector

v) Domicile Certificate

vi) Nursing Hospital Certificate/Discharge Card if minor is below 5 yrs

vii) Baptism or Marriage Certificate (for Catholics only)

viii) PAN Card

ix) Driving License

Non-standard age proof: Must be accompanied by Affidavit from the Customer for DOB confirmation under oath (on 100 Rs stamp paper attested by judicial magistrate only)

i) Voter's I Card

ii) Ration card

iii) ESIS Card

iv) Pension Card

v) Dependent ID/Family card

4.2 Address Proof

Address on proposal should match with that on the address proof submitted.

List of acceptable address proof

i) Address & Contact Number Proof on Company Letter Head / Employee ID cards

ii) Telephone Bill , Post Paid Mobile Bill, Broadband Bill

iii) Rent Agreement/ Lease Agreement/ Property Tax / Water Tax /House Tax/ Electricity bill/ Home Loan

Documents

iv) Driver’s license/Passport/ Gas Connection/Ration Card /Arms & ammunition License

v) Written Confirmation from Bank where the Prospect is a Customer, regarding identification and proof of

residence



vi) Bank Statement / Bank Passbook / Fixed Deposit Certificate / Credit Card Statement

vii) Any Life Insurance: Premium Receipt / Welcome letter /Policy Bond etc..

viii) Last year’s Health Policy document (Portability cases)

ix) Any vehicle RC Copy

x) Pan Card Intimation letter / Voter Id Card/ Income Tax Returns

xi) PPF /NSC /any other Investment Certificate

xii) Any Government issued document for Address Proof eg: rashan card (from Gram Panchayat, State Govt

etc)

xiii) Monthly Maintains bills for Bldg Society/ Chwals/Flats/Plots

xiv) Regiment Certificate for Army Personnel

xv) Insurance policy document for Vehicle Insurance ( including, 2 wheelers & LMV )

xvi) Adhar Card

xvii) AMHI Renewal Notice (when the customer moves from an existing EH policy to a New Product (eg: Restore

xviii) In absence of above, an Affidavit from the Customer for Address & Telephone Number confirmation. ( e-

stamp paper mode is also acceptable )

List of acceptable standard address proof is as per the circular shared by operations department. Any

subsequent circular shall supersede this list.

Note:

i) Address proof is compulsory for Agency, Partnership, AES and Digital (offline cases)

ii) Any Bill or Statement for Bank, Credit Card, Mobile, Bank Pass Book etc. That is submitted to us, should

not be more than 3 months old from Bill Generation date or Bill Payment date.

iii) All policies from Thane/Ulhasnagar location (up to 3 lacs sum insured) and Nashik, Ghaziabad, Faridabad,

Bulandshehar, Vapi, Dhaund, Talegaon (Pune) and Jalgaon locations within city/area limits only (for all

sum insureds) have standard age proof (for proposer), photo ID proof (for proposer and all insureds of age

18 and above), address proof (of proposer) and photograph (mandatory for all insureds). Responsibility to

ascertain adherence to this guidelines vest with local or branch operation person, who would identify the

cases as per criteria defined and confirm to the requirements by mentioning the same on the check list.

List of cities shared is not exhaustive, and shall be updated on regular basis.

4.3 Proposer not getting covered himself or covering self alone

1) Both Self & Spouse or Father & Mother ( where son or daughter are proposing) should opt for same sum

insured.

2) Coverage be allowed for single insured (Self or Spouse/ Father or Mother) only in case if other one is

uninsurable (Medical conditionor under age) or has same or greater amount of coverage under indemnity

based individual health insurance from insurer in India.

4.4 Financial Underwriting:

i) All sum insured ranges for the product would be available, irrespective of earning status of insured's

(Earning/Non-earning) and coverage on other family members

ii) Where proposer is not a proposed insured person, sum insured asked for roughly should not exceed 5

times of annual income of the proposer.

5 Special Cases

i) Employer employee cases: Existing guidelines may be followed i.e. Employer can be the proposer and

premium payor for employee’s policy

ii) Counter offer (Risk loading) cases:

a. If loading is paid in cash or any other mode except cheque/credit card, written consent is

mandatory for issuance

b. If loading is paid by cheque/credit card by proposer, consent is not mandatory

c. If loading is paid by cheque/credit card by person other than proposer, consent is mandatory



6 Declined Conditions List

Members with any of the following conditions / ailments or history of the same shall not be offered health insurance cover currently.

i) Diabetes Mellitus or Impaired glucose tolerance

ii) Coronary Artery Disease (Angioplasty/Coronary bypass/Heart attack)

iii) Congestive Heart Failure/ Conduction Abnormalities of Cardiac System/ Pace maker implantation iv) Cerebrovascular Accident (Stroke)

v) Malignancy or Cancer (Leukemia, Sarcoma, etc)

vi) Auto Immune Diseases (Rheumatoid Arthritis, SLE, Ankylosing spondylitis etc.)

vii) Renal Transplant/ Congenital disorders of Renal System

viii) Cirrhosis (Alcoholic/Nonalcoholic)

ix) Multiple Sclerosis

x) Epilepsy xi) Mental Retardation

xii) Genetic Disorders

xiii) Psychiatric disorder

xiv) Renal failure /Chronic renal disorder/ ESRD (End stage renal disorder)

xv) Paralysis

xvi) Inflammatory bowel disease (Crohn’s disease and Ulcerative colitis)

Please note that this list is enumerative only & conditions may be added or deleted based on our experience. All such changes shall be communicated to all the concerned before implementation in future.

7 Premium payment

3) Cheques / Demand Drafts / Cash and Credit cards are accepted

4) Cheques are permitted from the following entities:

-Self, Spouse or any of the blood relative of proposer or a business partner or employer (Employer

employee case). In case of business partner, consent / declaration of other partners is not manadtory if the

premium is paid from partnership firm`s bank account.

5) Forms wherein premium is paid by third party (one who is neither proposer nor one of the insured), a third

party declaration needs to be submitted.

6) Benefits of Sec 80 D under income tax would be available for payment in any mode other than cash. This

benefit shall be available to the payor of the premium only, if either proposer, one of the insured or

Son/daughter/Father/Mother/Spouse of the insured.

7.1 Cheque Dishonour

The cheque has to be drawn in favour of Apollo Munich Health Insurance Company Limited only.

In course of a cheque dishonor, the application or policy is cancelled.There are two options for the

customer

The customer has to sign a declaration [(available at branches – indicating his health status has not changed

and he agrees to change the policy start date to new date of payment and pay again within 7 days of the

cheque dishonor. (For portability cases payment against cheque dishonour has to be as per login criteria for

e.g. For PPC portability case payment should be received at least 30 days prior to previous policy expiry)

Customer can fill up a new proposal form and apply again if the above is not fulfilled within 7 days. It has

to be demand draft /Cash/Credit card.

For both the above cases, payment will accepted only by demand draft / Cash / Credit Card. Cheque will

not be accepted again or represented.



8 Pre Policy Check Up

PPC is triggered only after the applications are logged in at the branches. Member should be educated on PPC

tests that will be done. CUSTOMERS SHOULD NOT GO ON THEIR OWN FOR PRE-POLICY CHECK. Health India / UHC

/ any other TPA appointed by Apollo Munich will make an appointment with the customers over the phone. They

need to carry a copy of photo ID card for the tests.

Incase a customer does not turn up for the test / indicates he is not interested in tests/ not reachable,

then the sales team will be informed. Agents need to check up with the customer, take the new timings

and date and inform local office. HO will inform the TPA for customers’ preference.

If the customer does not get the PPC done within 21 calendar days from the date of login of the application

form the prospect will be cancelled (7 days in case of portability case)

Reimbursement – Incase a proposal is accepted after PPC, Apollo Munich will reimburse 50% of the expenses

incurred per insured person. The medical reports are valid for a period of 90 days (Sub-standard findings in

PPC)/ 180 days (Standard findings in PPC) from the date of Pre-Policy Checkup.

PPC is madatory for all applicants category of PPC would be decided based on the age and sum insured

opted under the product for any member with Apollo MUNICH, as per PPC grid of the individual product

only. This guideline would be followed unless there is any specific communication in this regard from

medical underwriting.

if the customer is not interested in undergoing PPC then the customer should give a written note for

cancellation of prospect or call our toll free to request cancellation. This would help sending the refund

immediately to the customer rather waiting for automated cancellation after 21 days.

Any reduction in benefit amount i.e. SI reduction would not alter the medical requirements, once

triggered. Medical requirements once triggered cannot be waived.

PPC Grid with details of tests is as below

Age\SI 2,00,000 3,00,000 5,00,000

61-65 ME, RUA, FBS, CBC,

Lipids, TMT or ( ECG& 2D

Echo), SGOT, Total

Proteins, Sr Creatinine,

PSA (males), USG Abd

(females)

ME,RUA,FBS,CBC,Lipids,TMT

or ( ECG& 2D Echo), LFT, Sr

Creatinine,PSA (males),USG

Abd (females)


or ( ECG& 2D Echo), LFT, Sr

Creatinine,PSA (males),USG

Abd (females)

66

onwards

ME,RUA,FBS,CBC,Lipids,T

MT or ( ECG& 2D Echo),

LFT, Sr Creatinine,PSA

(males),USG Abd

(females)


or ( ECG& 2D Echo), HbA1c,

LFT,RFT,PSA (males), USG

Abd (females)


or ( ECG& 2D Echo), HbA1c,

LFT,RFT,PSA (males), USG

Abd (females)

ME = Medical Examination (Report), CBC = Complete Blood Count, ECG = Electro Cardio Gram, FBS =

Fasting Blood Sugar, Lipids = Lipid Profile, Sr Creatinine = Serum Creatinine, PSA = Prostate Specific

antigen, RUA = Routine Urine Examination, TMT = Treadmill Test, USG = Ultrasonogram, SGOT – Serum

Glutamic Oxaloacetic Transaminase, HbA1c – Glycoslated Hb, LFT= Liver Function Test, RFT= Renal

Function Test



Following would be the PPC requirements while porting from Easy Health product to Optima Senior

9 Risk Start Date Logic

Risk start date would be later of the Proposal sign date, Login date, Requirement completion date and previous

policy expiry date (in case of portability case).

Example 1) Payment made through cheque dated 21.07.09 Requested Start date 21.07.09 Proposal sign date 20.07.09 Case status NON PPC/NON Portability Application received date at AMUNICH office 25.07.09 Start date should be 25.07.09 as application form received at AMUNICH is 25.07.09 Example 2) Payment made through cheque dated 15.07.09 Requested Start date 21.07.09 Proposal sign date 21.07.09 Case status NON PPC/NON Portability Application received date at AMUNICH office 26.07.09 Start date should be 26.07.09 as application form received at AMUNICH is 26.07.09 Example 3) Payment made through cheque dated 10.07.09 Requested Start date 21.07.09 Proposal sign date 12.07.09 Case status NON PPC Previous Policy expires on 20.07.09 Application received date at AMUNICH office 12.07.09 Start Date should be 21.07.09 as previous policy renewal date (requirements completed prior to previous

policy expiry). Example 4) Payment made through cash dated 21.07.09 Requested Start date 30.07.09 Proposal sign date 15.07.09 Case status NON PPC Previous Policy expires on 29.07.09 Application received date at AMUNICH office 21.07.09 Start Date should be 30.07.09 as previous policy renewal date (requirements completed prior to previous

policy expiry). Example 5) AMUNICH Renewal case Payment made through cheque dated 01.08.09 Previous policy expired 25.07.09

Easy Health Sum

Insured

Optima Senior Sum Insured

(Lac)

PPC

1,2,&3 2 No PPC

4 and above 2 No PPC

1 3 As per optima senior grid


1,2,3 5 As per optima senior grid




Start Date should be 01.08.09 however portability benefits will be extended in the policy as application received within 30 days from the date of expiry of the previous as per IRDA circular.

Example 6) Payment made through cheque dated 17.07.09 Requested Start date 17.07.09 Proposal sign date 17.07.09 Case status PPC/NON Portability Application received date at AMUNICH office 26.07.09 PPC done 29.07.09 Reports received at AMUNICH office 30.07.09 Start Date should be 29.07.09 the day when PPC was done (later of application received date,

requirement complete date) Example 7) Payment made through cheque dated 05.07.09 Requested Start date 15.08.09 Proposal sign date 04.07.09 Case status PPC/Portability Case Previous Policy expires on 14.08.09 Application received date at AMUNICH office 11.07.09 PPC done 18.07.09 PPC reports received 19.07.09 Requirement raised 20.07.09 Requirement fulfilled and received at AMUNICH office 25.07.09 Start Date should be 15.08.09 as previous policy renewal date (requirements completed prior to previous

policy expiry). Example 8) Payment made through cheque dated 16.08.09 Proposal sign date 16.08.09 Case status NON PPC Application received date at AMUNICH office 18.08.09 as 17.8.09 is holiday Start Date should be 16.08.09 as payment received date is 16.08.09 Example 9) Payment made through cheque dated 16.09.09 Proposal sign date 20.09.09 Case status NON PPC Application received date at AMUNICH office 20.9.09 Start Date should be 20.09.09 as application form signed date and proposal received date is 20.09.09

10 Risk Start Time Logic

Risk start time is a mandatory field and to be recorded as per below mentioned logic in all Optima Senior

proposals.

For New Business ( Clean Proposals)

There would be NO change in current Risk Start Date logic.

Risk start time would be captured and displayed in 24 hrs format ( 00:00)

BO ops would record risk start time on all proposal form via stamp, proposal submission time at BO

would be considered as risk start time.

Data Entry team would enter the recorded time in Elixir mandatorily only in Optima Senior proposals (

New field being created in Application Tab)

Entered time would be displayed on the policy schedule, risk end time for all policies would be 24:00

hrs on policy expiry date

Eg: 14:30 Hrs on 01-01-2012 to 24:00 Hrs on 31-12-2012.



For New Business ( PPC Cases)

Proposals where PPC is done RST would remain the same as recorded earlier

For New Business ( Loading/Consent Cases)

Proposals where loading/consent is required entered time would be altered

BO/TO ops record submission time on the letter

TU Team would alter time in elixir as per as mentioned on the letter.

For Renewal Cases

Where policies are renewed before due date RST as 00:00 shall appear

Policies renewed during the grace period BO/TO to record time on renewal notice as per above

process.

11 Portability

Most health insurance plans offered by general or health insurers in India have waiting periods, exclusions which reduce based on the number of years of continuous cover. Portability will ensure that these accrued benefits are transferred at par to the new insurer at the time of porting and consumers do not lose on these benefits while switching insurers. The credit gained will be applicable to:

i) General waiting period

ii) Waiting periods for coverage pre-existing conditions

iii) Any time bound exclusions (for example 2 year waiting periods for listed conditions in Optima Senior) Application timelines

i) In case of adversity in proposal form / claim declaration/PPC as per medical grid - 21 days before renewal date

ii) In case of medicals to be conducted or additional information required, customer must complete the same or provide requisite documents within 7 days of intimation from the company.

Documentation

For availing portability benefits following documents are to be submitted in addition to duly filled portability form-:

i) Copy of the previous years Policy Schedule issued by the previous Insurer OR Renewal Notice ( We would provide portability benefits to the extent of documentary proofs provided /made available, in case we do not receive information from your existing insurer.)

ii) Self-declaration by customer regarding no claims made

iii) Questions regarding previous and existing health insurance details in the Proposal Forms should be mandatorily filled.

iv) If there is a claim in existing policy, then discharge summary, investigation and follow up report copies v) If there is a past medical history, then consultation papers, prescription, investigation, treatment and

report copies.

Optima Senior product offers a NON CUMULATIVE 5% No Claim Discount for every claim free year, for the purpose of portability Case of NCB/NCD in the existing product ( to be ported to AMHI)

If incoming product is a CB (Cumulative bonus), we would not port any CB as Optima Senior product does not support Cumulative Bonus feature. For checking claim status existing guidelines for matching CB would prevail.

a. If NCD product, in that case

If incoming product is a NCD (No Claim Discount) we would not port any NCD as Optima Senior product offers a NON CUMULATIVE discount on continuous renewal of the policy.

i. Customer declaration of claim for “all” previous policy years on proposal form (Q No 6)

be mandatory.



ii. Policy documents for latest 3 or 4 years (as per ported product’s PED e.g. Easy health 3 years) only need to be submitted if

1. NCD reflected in submitted documents as more than “Zero” (if same should be more than Zero as per incoming product guidelines).

2. NCD reflected in first policy (no previous policy no or reference is given) as “Zero”, but in rest following years as more than “Zero” (if same should be more than Zero as per incoming product guidelines).

iii. In case of claim as declared on proposal form or NCD is “Zero” (if same should be more than Zero as per incoming product guidelines), medical documents related to claim and all year’s policy documents would be mandatory.

If No CB/NCD product (i.e. No CB AND No NCD) in that case

I. Customer declaration of claim for “all” previous policy years on proposal form (Q No 6) be mandatory.

II. Policy documents for latest 3 or 4 years (as per ported product’s PED e.g. Easy health 3 years) only need to be submitted.

III. In case if customer opts for lesser year of portability as per submitted documents, then declaration in same regard needs to be in place on proposal form and we shall process for portability benefit as per given documents.

IV. In case of claim as declared on proposal form, medical documents related to claim would be mandatory.

12 Renewals

i. Apollo Munich policy’s renewal request can be accepted maximum up to 60 days prior to policy expiry date

ii. In case of any requirement raised for renewal (Member addition, SI enhancement etc) e.g. PPC, Add

info, Risk loading or exclusion, etc, same needs to be complied to within 7 days. iii. Grace Period allowed -30 days post expiry of policy

iv. Sum Insured Enhancement – Sum Insured can be enhanced only at the time of renewal subject to no

claim have been lodged/ paid under the policy. If the insured increases the sum insured one grid up, no fresh medicals shall be required. In cases where the sum insured increase is more than one grid up, the case may be subject to medicals (refer guidelines below). In case of increase in the Sum Insured waiting period will apply afresh in relation to the amount by which the Sum Insured has been enhanced. However the quantum of increase and pre-policy check up requirements shall be at the discretion of the company.

a) No PPC be called for cases in renewal, where there is No SI enhancement, member addition is

requested.

b) SI enhancement is allowed only in case if no claim in the policy. However request may be logged in and

final decision on acceptability would be taken after complete underwriting only.

c) In case if SI enhancement requested of 1 band only, No PPC be required unless called by medical

underwriter based on underwriting guidelines

d) In case if SI enhancement requested for more than 1 band

If revised policy benefits (SI) falls under non-medical limits of PPC grid as per attained age band,

No PPC would be required unless called by medical underwriter based on underwriting guidelines.

If revised policy benefits (SI) falls under medical limits of PPC grid as per attained age band, PPC

would be mandatory.

13 No Claim Discount

Optima Senior product provides a NON CUMULATIVE 5% NO Claim Discount each renewal.

For 1 year policy – 5% NCD for a claim free year, in case of a claim NCD provided would be NIL.



For 2 year policy – 5% NCD if both years are claim free, in case of a claim in either of the NCD would not

be provided.

Unlike cumulative bonus the “No claim discount” (NCD) has financial impact on the premium. Renewal premium

would change where claims have been settled post generation of renewal notice or renewal of policy. Following

are the scenarios with process handling

1. Where claim is settled post generation of renewal notice but before renewal of policy

Activity Level

A system generated letter would be dispatched by HO Ops team (Retail) to the

customer mentioning additional premium requirements

HO Ops (Retail)

These letter would be available in Output > Letters > Individual > Operations

> Optima Senior Revised Premium for dispatch

HO Ops (Retail)

Receipting of additional/revised premium ( discounted + additional premium )

at branch

BO/TO/RO

Post receipting assigned the case in the TU queue for further processing BO/TO/RO

2. Where claim is settled post renewal of policy

Activity Level

A system generated letter would be dispatched by HO Ops (Endorsement

Team) to the customer mentioning additional premium requirement

HO Ops (Endorsement)

These letter would be available in Output > Letters > Individual >

Operations > Optima Senior Additional Premium for dispatch

HO Ops (Endorsement)

Receipting of additional premium at branch and create a CRM case (Current

process for Member Addition to be followed while creating a CRM case.)

BO/TO/RO

Post receipting assigned the case in the TU queue for further processing BO/TO/RO

14 Endorsements

Endorsements Type

Pre-Inception

Documents Required

Post-Inception/ Renewal Documents Required

Policy Cancellation

- - Allowed Letter from the client.

No paid claims. Short period refund

Change in Sum Insured

Allowed

Letter from the Client

Premium payment.

Allowed only at Renewal

Change Request Form/ Email from registered mail id

Addition of Member

Allowed

Proposal Form from the Client,

Premium payment.

-Allowed midterm only in 3 scenarios -Other additions only at Renewal

Proposal Form from the client, Premium payment

Mid- term allowed for newly married spouse.

Deletion of Member

Allowed Letter from the

Client

Allowed mid term only on death of

member For other cases at

Renewal

Letter from the Client/ / Email from registered mail id

No paid claims. Short period scale refund



Policy Period change


Client Not Allowed -

Corrections


Client

Allowed

Change Request Form /Letter from the Client/ Email from registered

mail id and other supporting documents

(Name, Gender

etc)

Address /Nominee

change Allowed


Allowed

Change Request Form /Letter from the Client/ Email from registered

mail id and other supporting documents

Contact Details Allowed Intimation from

Client Allowed Intimation from Client

Change of DOB Allowed


Premium payment,

Documentary evidence

Allowed

Change Request Form /Letter from the Client// Email from registered

mail id Premium payment,

Documentary evidence

Note: Incase of any data entry error, intimation from client in any form will be accepted.

15 Glossary

i) Insurable interest: Insurable interest exists when an insured person derives a financial or other kind

of benefit from the continuous existence or well-being of the insured subject. A person has an

insurable interest in something when loss-of or damage-to that thing would cause the person to

suffer a financial or other kind of loss. E.g. Parents have insurable interest in their children,

Husband has insurable interest in his wife and vice versa, etc.

ii) Insurability: Insurability means whether a particular client can be insurable by an insurance

company, because of the quality assigned pertaining to the risk that a given client would have. An

individual with very low insurability may be said to be uninsurable, and an insurance company will

refuse to issue a policy to such an applicant.

iii) Indemnity: Refers to compensate another party to a contract to the extent of loss, which such

other party may suffer during the performance of the contract. The financial loss has to be real and

incurred. E.g. A (Insured) gets into indemnity health insurance contract with B (Insurer/Insurance

Company), A would be compensated for lower of the incurred expenses or sum insured, by B in case

of health expenses incurred during policy period as per contract terms & conditions. Suppose if A has

policy with B for sum insured of 100000 Rs, and incurs medical expenses of 60000 Rs, he would get

reimbursement of 60000 Rs. And if incurred expenses are beyond sum insured limits, say 120000 Rs

he would get 100000 Rs.

iv) Material fact: Is a fact whose expression/concealment would reasonably result in a different

decision of entering into contract of insurance. The principle of “utmost good faith” requires anyone

seeking insurance to disclose all the material facts about the risk that he knows, or should know.

Right to decide if the given fact is material or not vests with insurer, and not the insured. Hence

every fact pertaining to the risk needs to be disclosed to the insurer prior to the formation of

insurance contract. E.g. Insured declaration of not suffering from diabetes when he actually is may

result in policy issuance, instead of refusal of the policy if the fact would have been disclosed to the

insurer beforehand.

v) Nondisclosure: Failure or refusal to declare or reveal part or full information that is required to be

declared or revealed. E.g. Non-disclosure of past medical history of diabetes, Non-disclosure of past

medical history of diabetes with disclosure of past medical history of hypertension.

vi) Misrepresentation: Means a false statement of fact made by one party to another party, which has

the effect of inducing that party into the contract. E.g. Wrong date of birth provided to get

categorized for medicals free issuance (Non-medical- Age & Sum insured basis) OR if falling outside

entry age criterion of the product.

vii) Exclusion: A cause of loss that is not covered by an insurance policy.

http://en.wikipedia.org/wiki/Risk

http://www.businessdictionary.com/definition/failure.html

http://www.investorwords.com/1334/declare.html

http://www.businessdictionary.com/definition/information.html

http://www.businessdictionary.com/definition/required.html



viii) Earned income: Income ought to be earned by active participation in employment or self

employment (Business) activity. E.g. Salaried class, Managing partner of the firm, Proprietor, etc.

ix) Unearned income: Income which may continue even without active participation by its recipient.

E.g. Rental income, Pension income, etc.

x) Sum assured: is the fixed amount payable to the beneficiary on occurrence of insured event as per

policy terms and conditions. E.g. Critical illness benefit, Term life insurance, etc.

xi) Sum insured: is the maximum liability of the insurer under an insurance policy to which extent

incurred loss is payable, as per policy terms and conditions. E.g. Health insurance, Motor insurance,

etc.

xii) Morbidity: the rate of disease or proportion of diseased persons in a given locality, nation, etc.

16 Claim Procedure

What do I do in case of a claim or any assistance?

Intimation & Assistance Procedure for Reimbursement of Medical Expenses Procedure to avail Cashless facility



Please contact our designated TPA atleast 7 days prior to an event which might give rise to a claim. For any emergency situations, kindly contact our TPA within 24 hours of the event. Our TPA can be contacted through: - 24 x 7 Toll free line at: - 1-800-425-4033 - E-mail at: [email protected] - Fax at: 040-23541400 - Post/ Courier to: Claims Department Family Health Plan Ltd Srinilaya – Cyber Spazio, Suite No. 101, 102, 109 & 110, Ground Floor, Road No. 2, Banjara Hills, Hyderabad-500034 Please use the Claim Intimation Form available at our website for intimation of a claim.

Our TPA must be informed no later than 7 days of completion of such treatment, consultation or procedure. • Please send the duly signed claim form and all the information/documents mentioned* therein to your designated TPA within 15 days of the occurrence of the Incident. * Please refer to Claim Form for complete documentation. • If there is any deficiency in the documents/ information submitted by you, the TPA will send the deficiency letter within 7 days of receipt of the claim documents. • On receipt of the complete set of claim documents, your designated TPA will send the cheque for the admissible amount, along with a settlement statement within 15 days. • The cheque will be sent in the name of the proposer. Note: Payment will only be made for items covered under your policy and upto the limits therein.

For any emergency Hospitalisation, your designated TPA must be informed no later than 24 hours after hospitalization. • For any planned hospitalization, kindly seek cashless authorization from your designated TPA atleast 48 hours prior to the hospitalization. • TPA will check your coverage as per the eligibility and send an authorization letter to the provider. In case there is any deficiency in the documents sent, the same shall be communicated to the hospital within 6 hours of receipt of documents. • Please pay the non-medical and expenses not covered to the hospital prior to the discharge. • In case the ailment /treatment is not covered under the policy a rejection letter would be sent to the provider within 6 hours. Note: • Insured person is entitled for cashless only in our empanelled hospitals. • Please refer to the list of empanelled hospitals on our website Or the list provided in the guidebook or welcome kit. • Rejection of cashless in no way indicates rejection of the claim.