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Emp first Final Prospectus - · PDF fileMax Bupa Health Insurance Company Limited Corporate...
Transcript of Emp first Final Prospectus - · PDF fileMax Bupa Health Insurance Company Limited Corporate...
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
EF/S
P/1
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www.maxbupa.com
‘Max’, Max Logo, ‘Bupa’and HEARTBEAT logo are registered trademarks of their respective owners and
are being used by Max Bupa Health Insurance Company Limited under license.
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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
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($) Baseline cover includes a 48 month waiting period for pre-existing conditions & a 30 day no claims/waiting period from inception. (**) Emergency ambulance - Maximum of Rs. 2000/-per event for out of network. (*) A compulsory Co-pay of at least 20% applies to all insured older than 60 years. (***) A 9 month waiting period applies to maternity cover including all attached new born baby cover items. (@) Vaccinations would be covered till the next Policy anniversary after which the new born baby has to be included in the Policy for the coverage to continue. Note: Baseline cover benefits includes a maximum of 2 adult + 2 children on a family floater basis.
Overall Sum Insured (SI) Rupees
Baseline cover benefits ($), (*) 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: