Swasthya Kavach (Family Health) Policy

What is Swasthya Kavach?

The Policy offers a protection cover for you and your family for any injury or disease related contingencies like hospitalization, medical expenses, surgical expenses, Organ transplantation etc.The Policy covers the members of the Family consisting of you, your spouse and dependent children up to the age of 23 years on a floater basis. Coverage is under a single Sum Insured and no separate Sum Insured is required for each member of the Family. Thus each member of Family draws claim from the single Limit of Indemnity.

Unique Selling Proposition– Critical illness gives you an option of differential pricing on

differential treatment-you can take a low basic Sum Insured for the general ailments and the high critical illness sum insured protects you against more expensive treatments.

– The critical Illness Cover is a indemnification cover and not a benefit policy- Hence even after the critical illness is detected you continue to get renewals .

– First Time critical Illness Family Floater cover in India– When compared to IMI with the little more extra than one is required

to pay for his own cover, he can cover the entire family– Emergency Assistance service (No competitor is offering this feature)– It is one of the most inexpensive covers you can buy in the target

segment of below 45 years

WHO CAN OPT FOR SUCH COVERS?

Parents are not covered. Proposal only for self or for single member will not be accepted

Maximum of three dependent children From 91 days and up to the age of 23 can be covered

Premium chart based

Family

The fresh proposal up to the age of 55 shall only be accepted and can be renewed up to the age of 65

Oldest Member

Swasthya Kavach is offered under two Plans

Base Plan Wider Plan

II) Basic Cover with Critical Illness

Families who are located in rural areas, small towns

Families who would like tocover the family against unforeseen disease or accident in an affordable Plan.

Middle class families located in metros whoare looking for Health care financing at reasonable prices

I) Basic Cover only

Target Audience

Families who are looking for Health care financing at reasonable prices

Common Coverage under Base Plan and Wider Plan(with varying limits of Coverage)

# Room and ICU Charges

# Ambulance service expenses

# Daily Allowance for bearing miscellaneous expenses for the duration of Hospitalization

# Pre-Hospitalization and Post Hospitalization expenses including authorized home nursing

# Vitamin and tonics consistent with illness

Common Coverage under Base Plan and Wider Plan

# Doctor’s fees, Cost of Medicines, Pathological Tests, etc.

# Pre-existing disease after 4 continuous Policy years with us.

# Prosthetic Devices like Pacemaker, Artificial Limbs etc.

# Transplants including Donor’s treatment and organs transplantation cost

# Dental surgery and treatment following an accident

# Defined Day Care Surgeries

Common Exclusions under Base Plan and Wider Plan

Naturopathy, use of Ayurvedic treatment experimental or alternative medicine, procedure and treatment including acupressure, acupuncture, magnetic treatment and such other therapies. Any diseases or injuries related to hazardous sports like bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding or rock climbing etc.Any Genetic disorders.External medical equipment of any kind used at home as Post Hospitalization care, like wheelchairs, crutches etc.Treatment of obesity or condition arising there from (including morbid obesity) and any other weight control programe.First 10% of any admissible claim if he is suffering from either Diabetes or Hypertension and First 25% of the admissible claim amount in case he is suffering from both diabetes and hypertension.The above provision is applicable only for claims arising out of Diabetes and/or Hypertension.

Common Exclusions under Base Plan and Wider Plan Contd..

Additional Exclusions under the Base Plan• During the first two continuous years of the Policy, the expenses on treatment of diseases

such as Renal Failure, Heart Diseases, any type of Carcinoma/Sarcoma/Blood Cancer.

Diseases which are Pre-existing at inception of the first Policy. Diseases contracted during the first 30 days of Policy During the first year of the Policy, the expenses on treatment of diseases such as Tonsillitis/

Adenoids, Gastric or Duodenal Ulcer, Any type of Cyst/ Nodules/ Polyps, Any type of Breast lumps.

During the first two continuous years of the insurance with ITGI, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis, Choletithiasis and Cholecystectomy, Inter- vertebral Disc Prolapse (other than caused by an accident), Osteoarthritis, Varicose Veins / Varicose Ulcers etc.

Cosmetic or aesthetic treatment, general debility, use of intoxicating drugs, intentional self injury.

AIDS related expenses, venereal disease, congenital disease

Plans are differentiated by the limits in claims cost for individual diseases, sub limits and exclusions applicable. These Differences are

as under :- S.No Benefits Base Plan Wider Plan1. Cost of Health

Check up Not Applicable The reimbursement shall not

exceed the amount equal to 1% of the average Floater Sum Insured during the block of four claim free years of Insurance with Us.

2. Daily Allowance Rs 150 per day Rs 250 per day

3. Post – Hospitalization

Medical expenses up to 7% of Hospitalization expenses incurred up to max.30 days after Hospitalization maximum to Rs 7500

Relevant medical expenses incurred up to 60 days after Hospitalization on Disease/illness/ Injury sustained, which will be part of Hospitalization expenses claim

7. Sub limit per day for Intensive Care Unit

2.0% of the Sum Insured 2.5% of Basic Sum Insured

8. Additional Exclusions for first two continuous years of Policy

Chronic Renal failure or End Stage Renal Failure. Heart Disease. Any type of Carcinoma / Sarcoma/ Blood Cancer.

Covered

S.No Benefits Base Plan Wider Plan

4. Restriction on other hospital expenses in accordance with the room rent.

Applicable Not Applicable

5. Ambulance charges Rs. 750/-or actual whichever is less

Rs. 1500/- or actual whichever is less.

6. Sub limit per day for Normal Room expenses:

1.0% of the Sum Insured 1.5% Basic Sum Insured

S.No Benefits Base Plan Wider Plan

9. Add on features:

Cumulative Bonus

Not Applicable Increased by 5% of the Basic Sum Insured at each renewal in respect of each claim free year of insurance, subject to maximum of 50% of the Basic Sum Insured

Critical Illness Not Applicable Optional cover

10. Limit of Liability

Basic Sum Insured

under option I : Limit of Liability is the Sum Insured + Cumulative Bonus if earned for claim free year

under option II : the total Sum Insured of the Basic Cover and Optional Extension + Cumulative Bonus (if any) on Basic Sum Insured

S.No Benefits Base Plan Wider Plan

11 Specified List of treatments have Expenses limit per treatment per claim or actual whichever is less for example Cataract, Piles, Fistula, Tonsillitis , Sinusitis, Hernia , Knee/ Hip Joint Replacement, etc.

Applicable Not Applicable

List of Treatments Under Base Plan Treatment List Expense Limit per Claim

1) Cataract 7.5% of the Sum Insured subject to maximum of Rs. 15000/-

2) Piles, Fistula, 10 % of the Sum Insured subject to Fissure, Tonsillitis, maximum of Rs. 30000/- Sinusitis

3) Benign Prostatic 20% of the Sum Insured subject to Hypertrophy, Hernia maximum of Rs.50000/-

4) Knee/ Hip Joint 50% of the Sum Insured subject to Replacement, All Cancer, maximum of Rs 200000/- Renal Failure

5) Appendicitis, Gall 15% of the Sum Insured subject to Bladder stones and maximum of Rs 40000/- Hysterectomy

It has to be kept in mind that the above Emergency Services will be provided as direct service to the Insured by Emergency Assistance Service Provider free of cost. There will be no facility of any cash payment under these heads or reimbursement of expenses incurred directly by the Insured or through any other service/ agency.

Benefits available

Sum Insured options are Rs. 200000/-, Rs. 300000/- , Rs.400000/- and Rs. 500000/- for two, three, four and five member family.

Policy is not portable which means that benefits enjoyed in other policies of ITGI or policies with other insurer (other than similar floater cover) are not transferable. ( Transfer Only to the Wider Plan)

Emergency Assistance Services are available with all the plan options and remains the same in scope of cover as in IMI and IAH policy.

Third Party Administrator is RakshaTPA.

Emergency Assistance Services Provider

Medical Consultation, Evaluation and Referral

Emergency Medical Evacuation

Care and/or Transportation of Minor Children

Emergency Message Transmission

Return of Mortal Remains

Emergency Cash Coordination

Medical Repatriation

Transportation to Join Patient

Premium Table

ITGI provides for the Policy with the premium based on Age, the Plan and Family size as applicable from time to time. Dependent parents are not covered.

1. Base Plan 2. Wider Plan

with two options viz.

The cover is provided under two Plans

a) Basic Cover b) Basic Cover + Critical illness Highest Age

Age limit: Proposer 18 years to 60 years

Children 91 days to 23 years

Premium Table Premium Table is provided with following options

1) Proposer + Spouse2) Proposer+ Spouse + 1 child

3) Proposer + Spouse + 2 children4) Proposer + Spouse + 3 children

5) Proposer + one child6) Proposer + two children

7) Proposer + three children

Premium is provided without Service Tax and therefore needs to be loaded accordingly.

Individual and self alone proposal with parents are not covered . The parents can take separate proposal and cover themselves..

Premium comparison for Sum Insured ofRs. 200000/- for a family of 2 adults + 2 children

Underwriting Process

Raksha TPA shall be issuing the member cards and the Beneficiary Guide, which will also carry the contact numbers of Emergency Assistance Service Provider for availing the aforesaid special services.

The Policies shall be accepted and written by all the operating offices up to the age of 45.The proposal with Pre-existing disease and/or with the age of 45 years shall require approval from Corporate office.

The premium is based on the highest age in the family, the size of the family , the sum insured and the type of Plan

Claim Form

Discharge Summary, Bills and Receipt of Hospital/Nursing, Home Attending Doctor’s Report and Bills as well as cash memos of medicines and pathological tests duly supported by proper prescription.

F.I.R, Post Mortem Report, Final Investigation Report etc. in case of an accident.

Documents required for settlement of claims

Claim ProcessThe claims process for the cashless claim settlement shall remain the same as at present under IMI Policies but for the change in TPA.

Emergency Assistance Service Provider shall only respond to emergency situations out side the home town of the insured person(during travel beyond 150 kms. within India) and the TPA takesover from the time the insured person is actually admitted as an inpatient in a hospital.

Dedicated center of RakshaTPA at Faridabad shall act as the centralized processing unit for all claims under this Policy whether on Cashless or Reimbursement basis or for claims under Personal Accident Benefit. This exclusive center will be in constant coordination with AAMESIL and our Health Claims Unit at CCU to ensure that best possible service level are maintained.

Thank You