Reliance Health Gain Policy Customer Information Sheet ...

Reliance Health Gain Policy Customer Information Sheet

SI No Title Description Refer To Policy Clause Number

1 Product Name Reliance HealthGain Policy

2 What am I covered for a. Hospitalization Expenses - Expenses incurred on Benefit 1 hospitalization for minimum period of 24 hours. This shall also includes the medical expenses for AYUSH treatment and Day Care procedures

b. Pre and Post Hospitalization - This covers indemnifies Benefit 2 theInsured Person for Pre-Hospitalization Expenses for a period of 60 days and Post Hospitalization Expenses for a period of 60 days

d. Domestic Road Ambulance - This cover indemnifies the Benefit 3 Policyholder/ Insured Person up to an amount of Rs.1,500 / Rs. 3,000(as per Plan opted), per Hospitalisation on availing Ambulance services offered by a Hospital or by an Ambulance service provider based on Plans opted

e. Donor Expenses - This cover indemnifies the Policyholder/ Benefit 4 Insured Person upto 50% of Base Sum Insured subject to maximum of Rs. 5 Lakhs, in respect of the donor for any organ transplant surgery conducted during the Policy

f. Domiciliary Hospitalization - This cover indemnifies the Benefit 5 Policyholder/Insured Person upto 10% of Base Sum Insured subject to maximum of Rs. 50,000 in aggregate for Medical expenses incurred for availing Medical treatment at home which would have otherwise required Hospitalisation

g. Wellness Benefit 6 (i) Doctor Anytime / Free Health Helpline - This Service gives an Option to Insured Person for seeking medical advice through telephonic or online mode. (ii) Health Portal : This Service gives an option to Policyholder/ Insured Person to access health related information and services through Company's Website

h. Cumulative Bonus - This cover increases the basic Sum Benefit 7 Insured by 33.33% for every claim free Policy Year, subject to a maximum of 100% of Base Sum Insured. In case of claim made during the Policy Year, the limit of Cumulative Bonus would be reduced by 33.33% of the Basic Sum Insured in the following year.

i. Re-instatement of Base Sum Insured- One time automatic Benefit 8 re-instatement of upto Base Sum Insured after exhaustion of Sum Insured, subject to sublimit of 20% for related illness / injury

j. Call option for Enhancement of Base Sum Insured - Benefit 9 Under Call option the Policyholder shall be given an option for Enhancement of Base Sum Insured which will be equivalent to accumulated Cumulative Bonus subject to Base Sum Insured and Cumulative Bonus does not exceed Rs. 50 Lakhs. The call option is available at the end of 4 consecutive claim free Policy Years and ceases as the Insured Person reaches the age of 60years

Reliance General Insurance Company Limited. IRDAI Registration No. 103. An ISO 9001:2015 Certified CompanyRegistered and Corporate Office: Reliance Center, South Wing, 4th Floor, Santacruz (East), Off. Western Express Highway,Mumbai 400 055. Corporate Indentity No. U66603MH2000PLC128300. Reliance Health Gain Policy UIN - RELHLIP21514V022021RGI/MCOM/CO/RELIANCE-HG-CIS/Ver. 1.0/20112020. Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.

(Description is IIIustrative and not Exhaustive)

k. Claim Service Guarantee – Benefit 10 (i) Cashless Claims - 1% for every delay of 6 hours beyond 6 hours of receipt of all information /documents (ii) Re-imbursement Claims - 1% for every delay of 21 days beyond 21 days of receipt of all information/documents Maximum liability is limited to 6% Delayed Claim Amount. l. Policy Service Guarantee - In the event of delay in the Benefit 11 process of issuing a Policy beyond 10 Working days from date of receipt of all required and Completed documents, the Company shall provide a one time additional amount of Sum Insured of Rs. 10,000 / Rs. 20,000 basis plan selected m. Accidental Death Cover for No Claim Renewal - For Benefit 12 every claim free Policy Year, the Company offers Personal Accident Cover to the Policy holder who is also an Insured person, for an amount of Rs. 100,000 n. Insurance Renewal - One time automatic Policy extension Benefit 13 for a tenure of 1 year if the Policyholder/Insured suffers from named Critical Illness o. Modern Treatment - Coverage up to 50% of S.I under this Benefit 14 benefit for the medical expenses incurred during the Policy Year on Inpatient Treatment or Daycare Treatment or Domiciliary Treatment of listed Modern Treatment Methods

3. What are the major Following is a partial list of the policy exclusions. Please refer exclusion in the policy to the policy document for the complete list of exclusions: 4.1 a. Investigation & Evaluation (Code:Excl04) b. Rest Cure, rehabilitation and respite care (Code:Excl05) c. Obesity/ Weight Control (Code:Excl06) d. Change-of-Gender treatments (Code:Excl07) e. Cosmetic or Plastic Surgery (Code: Excl08) f. Hazardous or Adventure sports (Code:Excl09) g. Breach of law (Code: Excl10 h. Excluded Providers (Code:Excl11) i. Drugs or treatments (Code: Excl12) j. Wellness and Rejuvenation (Code:Excl13) k. Dietary Supplements & Substances (Code: Excl14) l. Refractive Error (Code: Excl15) m. Unproven Treatments-Code (Code: Excl16) n. Sterility and Infertility (Code: Excl17) o. Maternity Expenses (Code - Excl 18) p. STDs q. Dental Treatment r. Treatment outside Discipline s. Hearing Aids and spectacles t. External durable medical equipment u. Sleep Apnea v. External Congenital Anomaly w. Circumcision x. Vaccination and Immunization y. Aritifical Life support equipments z. Travel Charges aa. Donor Transplant Expenses bb. Non-Allopathy cc. Non-medical expenses dd. Out Patient Treatment ee. Overseas Treatment ff. Domiciliary Treatment gg. Self-injury


hh. Documentation charges ii. Charges other than Reasonable & Customary Charges jj. Transplant other than from human body kk. RMO charges, Service charge and alike ll. Nuclear Attack mm. War

4 Waiting Periods a. 36 months waiting period for Pre-Existing Disease 3 (Code: Excl01) b. 24 months waiting period for Specified disease/procedure waiting period code (Code:Excl02) c. 30 Days Waiting Period (Code:Excl03)

5. Payment Basis Payment on indemnity basis for all covers except for Accidental Death Cover for No Claim Benefit 1 Renewal which is on Benefit basis

6. Loss Sharing In case of a claim, this policy requires you to share the following costs: Expenses exceeding the following Sub-Limits a. Donor Expenses - 50% of Base Sum Insured subject to maximum of Rs. 5 Lakhs

b. Domiciliary Hospitalisation - 10% of Base Sum Insured subject to maximum of Rs. 50,000 in aggregate.

c. Modern treatment methods and Advancements in technology: Up to 50% of the Sum insured.

Co-Payment 1(21) 20% co-payment on the Assessed Claim Amount if the age of Insured Person at first entry under the policy is >=61 years

7. Renewal Conditions The policy shall ordinarily be renewable except on grounds of 6.15 fraud, moral hazard, misrepresentation by the insured person. Renewal shall not be denied on the ground that the insured had made a claim or claims in the preceding policy years.

8. Renewal Benefits Cumulative bonus: Benefit 7 a. Increase in the sum insured by 33.3% in respect of each claim free year subject to a maximum of 100% of SI.

b. In the event of claim the cumulative bonus shall be reduced at the same rate

9. Cancellation a. The Policyholder may cancel this Policy by giving 15 days' 6.12 written notice, and in such an event, the Company shall refund premium on short term rates for the unexpired Policy Period as per the rates detailed in the policy terms and conditions.

b. The Company may cancel the policy at any time on grounds of misrepresentation, non-disclosure of material facts, fraud by the Insured Person by giving 15 days' written notice.

10 Claims For Cashless Service: Insured may refer Pre-Authorization form 5 attached as Annexure-C to the Policy Wordings and for updated Hospital Network details refer the link https://www.reliancegeneral.co.in/Insurance/Self-Help/Cashless- Garages-and-Hospitals.aspx?network=Hospitals


b. For Reimbursement of Claim : For reimbursement of claims the insured person may submit the necessary documents to TPA/Company within the prescribed time limit as specified hereunder.

11 Policy Servicing Any issues related with respect to policy, kindly E-mail us at [email protected] and for correspondence contact us Reliance General Insurance Company Limited Correspondence Address – Reliance General Insurance., Winway Building 2nd & 3rd Floor, 11/12 Block No-4,Old no-67,South Tukoganj Indore(M.P) -452001 Contact No.- 022-41112600 Grievances/ a. Details of Grievance redressal officer refer the link Complaints https://www.reliancegeneral.co.in/Insurance/About-Us/Grievance- 6.29 Redressal.aspx b.IRDAI Integrated Grievance Management System- https://igms.irda.gov.in/ c. Insurance Ombudsman - The contact details of the Insurance Ombudsman offices have been provided as Annexure - B of Policy document Complaints 12 Insured’s Rights a. Free Look period of 15 days from the date of receipt of the policy shall be applicable at the inception. 6.25 b. Lifelong renewability (except on certain specific grounds) 6.15 c. Right to migrate from one product to another product of the 6.13 company (E-mail us at [email protected] and For correspondence contact us Reliance General Insurance,

Sl No. Type of Claim Prescribed Time limit 1 Reimbursement of Within fifteen days from hospitalization, day completion of hospitalization care and pre hospitalization expenses 2 Reimbursement of Within fifteen days from post expenses post completion of post- hospitalization hospitalization treatment

Winway Building 2nd & 3rd Floor,11/12 Block No-4,Old no-67, South Tukoganj Indore(M.P) - 452001 Contact No.- 022-41112600 d. Right to port the from one company to another company 6.14 (E-mail us at [email protected] and For correspondence contact us Reliance General Insurance, Winway Building 2nd & 3rd Floor,11/12 Block No-4,Old no-67, South Tukoganj Indore(M.P) -452001 Contact No.- 022-41112600 e. Change in SI during the policy term or at the time of renewal 6.23 E-mail us at [email protected]

f. Norms on TAT for Pre-Auth and Settlement of reimbursement.

13. Insured’s Please disclose all pre-existing disease/s or condition/s before 6.1 Obligations buying a policy. Non-disclosure may result in claim not being paid.

Legal Disclaimer Note: The information must be read in conjunction with the product brochure and policy document. In case of any conflict between the CIS and the policy document, the terms and conditions mentioned in the policy document shall prevail.

Sr. No Type of claim Prescribed Time Limit 1 Pre-Authorization Within six hours of receipt of necessary document. 2 Reimbursement of Within twenty one days of date hospitalization, day of receipt of last necessary care and expenses document.


Reliance Health Gain PolicyPre-Authorisation Form

Request For Cashless Hospitalisation Health Insurance Policy

f) Provisional diagnosis:

g) Proposed line of treatment: Medical management Surgical management

Intensive care Investigation Non-allopathic treatment

h) If investigation and/or medical management, provide details:

i. Route of drug administration:

i) If surgical, name of surgery:

To Be Filled By The Treating Doctor/hospital

a) Name of the treating doctor:

b) Contact number of the treating doctor:

c) Nature of illness/disease with presenting complaints:

d) Relevant clinical findings:

e) Duration of the present ailment: days

i) Date of first consultation: D D M M Y Y Y Y

ii) Past history of present ailment if any:

iii) ICD 10 code:

(Please complete declaration on Page 3 of this form)

(To be filled in BLOCK letters)Details Of The Third Party Administrator (To be filled in block letters)a) Name of TPA / Insurance Company:b) Toll free phone number:c) Toll free FAX:To Be Filled By The Insured/patienta) Name of Patient b) Gender: Male Female c) Age: Years Y Y Months M M d) Date of birth: D D M M Y Y Y Ye) Contact number: f) Contact number of attending relative:g) Insured card ID Number:h) Policy number / Name of Corporate:I) Employee ID:I) Currently do you have any other Mediclaim/Health insurance: Yes NoIf yes, company name:Give details:j) Do you have a family physician: Yes NoIf yes, name of the family physician:Contact number, if any:


k) How did injury occur?

l) In case of accident:

i. Is it RTA: Yes No ii. Date of injury: D D M M Y Y Y Y

iii. Reported to police: Yes No iv. FIR number:

v. Injury/disease caused due to substance abuse/alcohol consumption: Yes No

vi. Test conducted to establish this: Yes No (If Yes, attach reports)

m) In case of maternity: G P L A i. Date of delivery: D D M M Y Y Y Y

Details of patient admitted

a) Date of admission: D D M M Y Y Y Yb) Time: H H : M Mc) Is this an emergency/a planned hospitalization event?: Emergency Plannedd) Expected no. of days’ stay in hospital: dayse) Room type:f) Per day room rent + nursing and service charges + patient’s diet: Rs.g) Expected cost for investigation and diagnostics: Rs.h) ICU charges: Rs.i) OT charges: Rs.j) Professional fees Surgeon + Anaesthetist fees + Consultation charges Rs.k) Medicines + Consumables + Cost of implants (if applicable please specify, other hospital expenses): Rs.l) All inclusive package charges if any applicable: Rs.

m) Sum total expected cost of hospitalization: Rs.

Mandatory: Past history of any chronic illness If yes, since (month / year)

Diabetes Heart disease Hypertension Hyperlipidemias Osteoarthritis Asthma/COPD/Bronchitis Cancer Alcohol or drug abuse Any HIV or STD/Related ailments Any other ailment give details:

Declaration (Please read very carefully)

We confirm having read, understood and agreed to the Declarations on page 3 of this form:a) Name of the treating doctor:b) Qualification:c) Registration number with state code: Hospital seal (Must include Hospital ID) Patient/Insured name and signature

i. ICD 10 PCS Code:

j) If other treatments, provide details:


Patient’s/Insured’s signature

Hospital declaration:

1. We have no objection to any authorized Insurance Company official verifying documents pertaining to hospitalization.

2. All valid original documents duly countersigned by the insured/patient as per the checklist below will be sent to Insurance Company within 7 days of the patient's discharge.

3. All non-medical expenses, OR expenses not relevant to hospitalization or illness, OR expenses disallowed in the Authorization Letter of the Insurance Company, OR arising out of incorrect information in the pre-authorisation form will be collected from the patient.

4. We Agree That Insurance Company Will Not Be Liable To Make The Payment In The Event Of Any Discrepancy Between The Facts In This Form And Discharge Summary or other documents.

5. The patient declaration has been signed by the patient or by his representative in our presence.

6. We agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications.

7. We will abide by the terms and conditions agreed in the MOU.

Hospital seal Doctor's signature

Documents to be provided by the hospital in support of the claim:

1. Detailed discharge summary and all bills from the hospital

2. Cash memos from the hospitals/chemists supported by proper prescription.

3. Receipts and pathological test reports from pathologists, supported by note from the attending medical practitioner/surgeon recommending such pathological tests.

4. Surgeon's certificate stating nature of operation performed and surgeon's bill and receipt.

5. Certificates from attending medical practitioner/surgeon that the patient is fully cured.

Declaration by the patient/representative:

1. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer after the discharge. I agree to sign on the final bill & the discharge summary, before my discharge.

2. Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer is not liable to settle the hospital bill, I undertake to settle the bill as per the terms and conditions of the policy.

3. All non-medical expenses and expenses not relevant to current hospitalization and the amounts over and above the limit authorized by the Insurer not governed by the terms and conditions of the policy will be paid by me.

4. I hereby declare to abide by the terms and conditions of the policy and if at any time the facts disclosed by me are found to be false or incorrect, I forfeit my claim and agree to indemnify the Insurer.

5. I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment with respect to the claim, my right to claim reimbursement of the said expenses shall be absolutely forfeited.

6. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer.

Patient’s/Insured’s name:

Contact number:


Age of the

members

insured

Premium

(Rs.)

Sum

insured

(Rs

.)

Premium

(Rs.)

Discount,

if any

Premium

after

discount

(Rs.)

Sum

insured

(Rs.)

Premium

or

consolidat

ed

premium

for all

members

of family

(Rs.)

Floater

discount, if

any

Premium

after

discount

(Rs.)

Sum

insured

(Rs.)

51 years 11,800 3 lakhs 11,800 10,620 3 lakhs




Note: Premium rates specified in the above illustration are standard premium rates without any loading. Also, the premium rates are exclusive of

taxes applicable.

Total Premium for all members of

the family is Rs. 26535 when

each member is covered

separately.

Total Premium for all members of the family

is Rs. 23881.5 when they are covered under a

single policy.

Total Premium when policy is opted on floater

basis is Rs. 22276.

Individual and Floater Premium Illustra�on- Reliance Health Gain Policy

Coverage opted on

individual basis

covering each

Coverage opted on individualbasis covering

multiple members of the family under a

single policy (Sum insured is available for

Coverage opted on family floater basis with

overall Sum insured (Only one sum insured

is available for the entire family)

10% 22,276 0% 22,276 3 lakhs

Sum insured available for each

individual is Rs. 3 lakhs

Sum insured available for each family

member is Rs . 3 lakhs

Sum insured of Rs . 3 lakhs is available for

the entire family.

Reliance Health Gain Policy Customer Information Sheet ...

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