Frequently Asked Questions (FAQs) Group Easy Health Plan

Transcription

1 1. Can a customer buy multiple policies of Rs. 2 lacs each? Yes, customer can buy multiple policies of 2 lacs each as per current underwriting policy. 2. If the account holder is an NRI, what is the procedure for issuing the policy? The process will remain the same. The insured has to fill the enrolment form for group policy/ proposal form for Optima restore policy. 3. How can a customer avail value added services such as discounts at pharmacy and DCs? Please explain the process? Insured can get discounts at Apollo pharmacies by showing his ID card. (This is provided along with the policy). Respective pharmacy would require entry of the unique code present on this card for the applicable discount. 4. Will there be loading of any kind on renewal premium if Customer has taken claims in the policy in previous year? No, there will be no claim based loading on renewal premium on the individual. 5. Please clarify working of PED with few examples? The pre-existing diseases will be covered after waiting period of continuous coverage of 3 years. An example: If a customer with Diabetes (without any complications) has been accepted under the policy and any illness associated with Diabetes were to result in hospitalization, the coverage for such an hospitalization can only be provided if the event were to occur 3 years post first inception of the policy. 6. How does optional Critical Illness rider works? Please provide 3-4 case studies/ scenarios to explain? Expenses upto Rs. 50,000 incurred on In-patient & day care treatment for 8 critical illnesses will be covered. The sum insured will apply on Individual basis in case of Individual Policy and on Family Floater basis in case of Family Floater Policy. Listed Critical Conditions are - a. Cancer b. Open Chest CABG c. First Heart Attack d. Kidney Failure requiring Regular Dialysis e. Major Organ/ Bone Marrow Transplant f. Multiple Sclerosis with Persisting Symptoms g. Permanent Paralysis of Limbs h. Stroke resulting in Permanent Symptoms Example of cases where critical illness is opted- If insured get hospitalised for listed critical illness & the expenses claimed are more than Rs Inpatient sum insured: Rs. 100,000 Critical illness sum insured: Rs. 50,000 Claimed amount- Rs. 80,000 Apollo Munich Health Insurance Co. Ltd. Page 1 of 8

2 Post the claim for critical illness treatment The balance sum insured of Rs.70,000 can be utilized for further hospitalization in both individual/ floater policy. If insured get hospitalized for listed critical illness & the expenses claimed are less than Rs Inpatient sum insured: Rs. 100,000 Critical illness sum insured: Rs. 50,000 Claimed amount- Rs. 30,000 Post the claim for Critical Illness treatment The insured can claim for upto Rs. 100,000 for further hospitalization for any illness or accident (other than the listed critical illnesses) & upto Rs. 1,20,000 for listed critical illnesses in both individual/ floater policy. 7. Which all cities get covered under Mumbai Metropolitan region and Delhi NCR respectively? Please specify the names? Mumbai Metropolitan region: Mumbai, Navi Mumbai, Thane. Delhi NCR: Delhi, Faridabad, Noida, Gurgaon, Ghaziabad 8. If customer gets rejected under Canara Bank Optima Restore plan on the basis of medical underwriting, can he/she apply for the Canara Bank Group Health Plan? Yes, the customer can take group health policy. 9. Please explain the process of portability from Canara Bank Group Health Insurance Plan to Canara Bank Optima Restore plan of Rs. 10 lacs SI? Insured can move from Group health policy of Canara Bank to Optima Restore plan post completion of 1 year under the policy. The portability would be provided for number of years completed under the group policy. Any underwriting as applicable based on age and choice of sum insured will be applied as per the policy to which customer is porting. In this case the guidelines applicable to the Optima Restore policy offered to Canara Bank will apply. 10. Can this policy be given to pregnant lady? Please specify conditions, if any. No. 11. Who will be the contact person if customer needs support at the time of claim? The contact details provided on the Certificate of Insurance should be contacted to get the required guidance for required Cashless/ Reimbursement facility. 12. Upon closing the CASA A/c with Canara Bank, what will happen to the current policy? If we are informed of the cancellation of his CASA account we would cancel the policy and refund his premium as per cancellation policy under the policy. Apollo Munich Health Insurance Co. Ltd. Page 2 of 8

3 13. In above scenario as per Ques. 16, can customer take claim after closing the A/C since policy has not come to end for that year? Yes, if the claim was for the period under which the policy was active. 14. Is Annual Health Check up is over and above Sum Insured? Yes. At each renewal insured can get annual health checkup reimbursed upto the limit defined as per sum insured chosen. upto Rs 1000 (For SI of Rs 50,000) upto Rs 1500 (For SI of Rs 1 lac) and upto Rs 2000 (For SI of Rs 2lacs) 15. If customer transfers his account from MMR/ Delhi NCR location to Non metro location during the policy period, what will be the impact on the premium? There will be no impact on premium for the ongoing policy in existing year. Premium will be applicable as per the pin code of the branch. On renewal, if he gets his account shifted to non metro location, the rates will be applicable for Non metro location. 16. Customer is opening a fresh CASA account. Can he apply for Group health insurance simultaneously? Yes. As on opening an account, he becomes an accountholder, he can now opt to have group health insurance policy simultaneously. 17. Will we send the photocopy of the enrollment form of Canara Bank Group health policy or Optima Restore proposal form filled by the customer along with the Policy Kit? Enrolment form for group or proposal form for Optima restore as filled by customer is for insurer s reference only. The customer will be given certificate of insurance which will provide details of the benefits that will be covered in the policy. 18. If customer has an individual policy for himself, attached with his saving A/C and floater policy attached with his spouse s saving A/C, Can the person avail cashless in both the policies? Yes, the customer can avail cashless facility in both the policies. 19. If Mr. A is the A/C holder of Canara Bank and proposes for spouse s parents. Since the account holder will not get any tax benefit u/s 80 D, the Parents in law wants to pay the premium to avail tax benfit under section 80 D, can they do it even if they do not have any A/C with Canara Bank? The account holder will be the proposer of the policy and will pay the premium from his account. The parents in law are not the account holders & cannot pay the premium. So, they cannot avail tax benefit through this policy. 20. Please list out the documents, customer needs to submit with the enrollment form for Group Health Insurance and Optima Restore Plan? In case of group health policy only enrolment form needs to be submitted. While for the Optima Restore plan, the application form needs to be submitted. Any additional documents related to the underwriting requirements for Optima Restore may also require to be included as the case may be. Apollo Munich Health Insurance Co. Ltd. Page 3 of 8

4 21. Is there any provision for customer to change Canara Bank Marketing Officer or Investment Officer in future if he is not satisfied with the services? We capture details of Specified person with us, who can be changed at renewal by the corporate agent. We don t capture details of marketing officer/ investment officer. 22. Why can t customer add child in mid of the Group health policy year? Any endorsement in terms of Addition & deletion of the member can be done only during the policy renewal. 23. What will happen to the dependent child s policy once he is 21 years of age if does not have A/C with Canara Bank? He can take a separate retail policy from us, portability guidelines as applicable would apply. 24. If customer s A/C shows insufficient balance/error in transaction, what is the next step for payment? We will raise a request for additional premium and wait for a pre agreed number of days before closing policy and refunding any premium if received. 25. Customer has Current A/C with Canara Bank in the name of his company/enterprise; can he apply for his employees and their dependents for Group health Insurance or Optima Restore plan? The policy covers only individual or family members. The coverage is not extended to employees/ corporate. 26. If the account holder is holding loans or defaulter in payment of loan, can he still apply for the health plan? Yes, an account holder can still apply for the insurance plan. 27. What if contract between Canara Bank and AMHI ceases? What would happen to Group health policy and thus to the Individual Optima Restore policies sold by Canara Bank? In case of the group policy as the contract is a group policy, post cessation of the group policy the coverage for the members in the group policy will continue only upto date certified in the COI. In case of Optima Restore as the policy is a retail policy the customers enrolled in the Optima Restore will continue to remain customers of Apollo Munich. 28. Are there any documents that the customer needs to submit to claim Annual Health Check up? If yes, please specify. Yes, the customer needs to submit the original receipt from the respective DC with details of expenses incurred in getting the health checkup done and also a copy of his health reports. 29. Which all documents need to be submitted to claim Accident Death and PTD claim under PA policy? The details of documents required for AD & PTD are mentioned below- Accidental Death a) Duly filled and signed Claim Form b) Policy copy c) Copy of FIR (First Information Report) /Spot d) Panchnama / Inquest Panchnama e) Death Certificate Apollo Munich Health Insurance Co. Ltd. Page 4 of 8

5 f) Original death summary g) Post Mortem Report h) Original legal heir certificate (in case nomination has not been filed by deceased) Permanent Total disablement a) Duly filled and signed Claim Form b) Policy Copy c) Copy of FIR (First Information Report) d) Original treating doctor certificate describing disablement e) Original Discharge summary from the hospital f) Original photograph of the injured reflecting disablement g) Prescription and consultation papers h) Leave certificate from the employer (If Employed) i) Disability Certificate issued by Civil Surgeon or equivalent as authorised by State Government j) Medical reports, case histories, investigation reports, treatment papers as applicable 30. If customer has Easy Health retail from AMHI and Canara Bank Group health policy for Rs. 1 lac each and claim amt. is for 1.50 lacs. Can he take Rs. 75 K from Easy Health and remaining Rs.75 K from Canara Bank Group health policy? If yes, will both the products offer Daily cash benefits? Yes, he can utilize 75 lac s from each policy. Yes both policies will offer daily cash benefits as defined under each policy. 31. Is there any minimum balance or transactions to be done in customer s CASA A/C to apply for the health plan? As the policy will be provided on voluntary selection, there will be no such requirement for minimum balance. 32. Scenario 1: Customer has taken a Canara Bank Group Health Insurance for Rs.2 lacs with Rs 50 K optional critical illness rider. He takes a claim for Rs. 2 lacs for hospitalization due to accident. After two months, he suffers with Critical Illness. What would be the available Sum Insured? Scenario 2: Customer has taken SI of Rs. 1, 00,000 and with CI (for Rs.50,000). Customer was diagnosed as Stroke and the claim was Rs.80, 000. How much will be settled and what will be the balance cover available for same disease and other disease? Scenario 3: Customer has taken SI of Rs. 1, 00,000 and with CI (for Rs.50, 000). Customer was diagnosed as Stroke and the claim was Rs.50, 000. Later he was diagnosed with Cancer and treatment cost was Rs.80, 000. How much will be settled and what will be the balance cover available for same disease and other disease? Scenario 4: Customer has taken SI of Rs. 1, 00,000 and with CI (for Rs.50, 000) under family floater. Self was diagnosed as Stroke and the claim was Rs.20, 000. Later after few months his spouse wants for cancer treatment was Rs.50, 000. How much will be settled and what will be the balance cover available for same disease and other disease? Scenario 1: As the insured has utilized Sum insured of for hospitalisation & will still have Rs sum insured that can be utilized for critical illness. Scenario 2: As the sum insured get enhanced in this case, complete 80,000 will be settled for critical illness claim. Balance sum insured of 70,000 will be left that can only be utilized for any hospitalization. Apollo Munich Health Insurance Co. Ltd. Page 5 of 8

6 Scenario 3: Both the claims will be settled as the sum insured get enhanced by For the first critical illness claim, complete CI cover of will be utilized & settled. During the occurrence of second critical illness claim, the customer is left with hospitalisation sum insured of which will be settled for critical illness hospitalisation as he had opted for the same. Scenario 4: Both the claims will be settled as the sum insured get enhanced by During first incidence, sum insured has been utilized. During second occurrence, the family will have sum insured left for for critical illness and 100,000 hospitalization which can be used in subsequent critical illness hospitalization. 33. What would be the risk inception date in the following scenario: Enrollment form filled: DSR raised: Premium Debit from customer s account: Enrollment Form reached AMHI: Policy Issued: Risk inception date would be considered as the date at which premium is debited from customer s account: i.e Mr. A aged 56 undergone Master health check up 1 month before and now he wants us to consider the same for Optima Restore. Can we consider the same? Will we reimburse 100% for PPC if policy gets issued? Yes, we may consider the master health checkup for PPC on prior underwriting approval. We would not reimburse health checkup cost in this case. 35. Can a foreigner working in India holding an A/C with Canara Bank buy AMHI s Group health insurance and optima restore plan? Yes. A foreigner holding an account with Canara Bank can buy group health insurance policy. 36. If customer has two A/Cs in Canara Bank and takes policy with A/C 1. After two years he closes A/C-1 and wants to attach this policy with another A/C. Can he do that and what will be the impact on the policy Yes, the customer can port from account 1 to account 2 at the time of next renewal. There will be no impact on the policy. 37. As we are aware that apart from AMHI, Canara Bank also has tie up with United India as well. So, will Canara Bank still sell United India s Health Insurance also along with AMHI s plan? Yes, Canara Bank would still be selling United India health insurance product. 38. What is the limit on number of policies one person can buy for Rs.2 lacs each for Easy Health Group Insurance? We do not currently have any limit on the number of policies that can be procured by a single individual. 39. Why maternity benefit is not covered under Easy Health Group Insurance while other Group plans do cover this? Every group plan is a customizable solution and largely dependent on the requirements of the Group Policy holder, this plan is designed for Canara Bank as per bank requirements of benefits and premium. 40. How DSR link will work? Apollo Munich Health Insurance Co. Ltd. Page 6 of 8

7 DSR will be an online link and be available on the CANNET. Once the respective fields are entered, a unique number gets generated. This has a search functionality too. 41. Can grandparents (CASA A/ C holder of Canara Bank) propose for their grandchildren? No. 42. Can Critical illness optional cover be included at the time of renewal? Yes, critical illness can be included at the time of policy renewal. 43. Can PA be included on renewal? Yes, PA can be included at the time of policy renewal. 44. Who will coordinate if customers do not receive policy kit? The customer / the Branch sales MO/IO can co-ordinate on behalf of the Canara Bank customer via /dedicated toll free number. 45. Can we do portability of United India Group to Apollo Munich Group plan? Why it is not allowed? No. Currently portability guidelines do not allow the same. 46. Why Easy Health Group Insurance does not have following features because for the customer, this will go as retail product and they are paying premium on their own. Grace Period Cumulative Bonus Free look period This is a group policy issued to Canara Bank who is the policyholder; all the mentioned benefits can only be provided to the policyholder. 47. Will contribution clause be applicable for Annual Health Check Up benefit in following scenarios? If a customer already has AMHI s Easy Health Retail policy for Rs. 5 lacs and takes AMHI s group health plan in addition through Canara Bank, which also offers him a health checkup benefit for Rs In case if he undergoes a Master Health Check up for Rs.7000 then can he claim this amount using both the policies he has? What If a customer buys Optima Restore for Rs. 2 Lacs and also Group Health Insurance for Rs. 2 lacs through Canara Bank? Now, both the plans offer him Annual Health Checkup benefit for Rs.2000 each. In case if he undergoes a Master Health Check up for Rs.4000 then can he claim this amount from both the policies? No, contribution clause would not apply. For above scenarios insured can reimburse upto eligible limits under both policies. 48. What is the AMHI s A/C number for crediting the premium collected, whether it will be printed in the payment slip? o Account Name: Apollo Munich Health Insurance Co Ltd. o Account No: o IFSC Code : CNRB o Customer ID : Apollo Munich Health Insurance Co. Ltd. Page 7 of 8

8 o Branch: Gurgaon DLF Galleria. 49. What is the definition of Diabetes with complications and Diabetes without complications? Diabetes without complications would mean where an individual has been diagnosed with diabetes but there no manifestation of co morbidities. Diabetes with complications would mean where a diabetic individual shows manifestation and existence of co morbidities such as heart related condition, retinopathy, diabetic foot etc. 50. Explain with examples the implications of Good Health Declaration in the application? Scenario 1 Customer signs up for Easy Health Group policy on 1-Jan He has diabetes since the past 7 yrs but under control and no further health complications. As per product underwriting guidelines, the customer is eligible to take the policy and the policy is issued. On 1-Mar-2014, the customer gets hospitalized for some treatment for an illness due to Diabetes, will the claim be paid? No. The claim will be declined. The customer has been having diabetes when he availed the policy. In this case, as per product guidelines, any hospitalization due to diabetes will fall under the WAITING PERIOD of 3 yrs and hence the claim would be declined. However the customer can claim expenses pertaining to Diabetes related Hospitalisation post the Waiting period of 3 years. Scenario 2 Customer signs up for Easy Health Group policy on 1-Jan He/ She is in good health at the time of taking the policy. On 3-Mar-2014, customer is diagnosed of Diabetes. On 3-Jun-2014, he/ she is hospitalized for treatment related to an illness caused by Diabetes. Will the claim be paid? Yes. The claim will be paid. The reason being, the customer has been diagnosed with diabetes only post availing the policy and hence is not qualified as a PRE-EXISTING DISEASE and 3 yrs waiting period is not applicable. While getting hospitalized, the doctors share the Prognosis report in which they would be capturing this information regarding the date of fist diagnosis of diabetes. Basis this, the authorization for the claim would be done. Apollo Munich Health Insurance Co. Ltd. Page 8 of 8