Frequently Asked Questions (FAQs)

Transcription

1 Q.43 In rural area customers do not know their exact DOB/age. Then how are age/date of birth defined? Ans: Documents submitted to Bank or Bank s record will be considered as age proof in absence of any other valid document. Date of FAQs Disclaimer: Policy document will be considered as final for any Policy related Coverages and Exclusions. Unique Product Features No medical check up to the age of 65 years Waiting period of only ONE year for specified diseases Day Care Benefit Day Care Procedures covered Domiciliary Hospitalization covered Frequently Asked Questions (FAQs) Group Health Insurance for SBI Account holders Call Now (Toll Free) Insurance is the subject matter of the solicitation. IRDA Reg. No. 144 dated 15/12/2009 Version 1.1, Sept 2013 SBI General Insurance Company Limited Corporate & Registered Office: Natraj, 101, 201 & 301, Junction of Western Express Highway & Andheri - Kurla Road, Andheri (East), Mumbai

2 Q.1 Who can buy the policy? Ans: Savings bank account holder and individual current account holder of SBI who is a resident of India can buy this policy. Q.5 What is the period of insurance? Ans: Period of insurance is 12 months from the date of debit of the premium amount from the account by the bank. Q.2 What does the policy cover? Ans: Policy covers medical expenses related to hospitalisation such as Room, Boarding & Nursing Expenses, Medical Practitioners fees, Expenses on Drugs and Medicines consumed during hospitalization period etc. Benefit Detailed scope of cover is as below: Room Boarding and Nursing Charges ICU Charges Coverage Details Medical Practitioner and Specialists Fees 1%/day for Non ICU and 2 %/day for ICU. All incremental expenses pertaining to room rent, medical practitioners/ specialists fees and other incidental expenses to be borne by the insured. Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Physiotherapy, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Prosthesis/Internal Implants and any Medical Expenses incurred which is integral part of the operation. Q.6 How & when will I receive my Certificate of Insurance? Ans: The Certificate of Insurance will be sent by post by SBI General to the address made available in the Proposal Form. The same will be dispatched by SBI General within 7 days from receipt of proposal at the office of SBI General Insurance. Q.7 What is a Floater Policy? Ans: Floater Policy is a type of health insurance cover wherein the entire family (in this case maximum of two adults and two dependent children) are covered under a single Sum Insured. Claims for hospitalization of any member of the family are payable up to the limit of the Sum Insured. Q.8 Is there any age limit for buying this policy? Ans: Yes. Minimum age at entry is restricted to 18 years. However dependent children from the age of 3 months can be covered under Floater policy subject to both parents concurrently covered with SBI General s Health Insurance Policy. The Maximum age of entry for the policy is 65 years for adults and 18 years for dependent children. Pre-hospitalization Expenses - We shall pay for expenses as defined in the policy and incurred up to 30 days prior to the date of admission into the hospital Post-hospitalization Expenses - We shall pay for expenses as defined in the policy and incurred up to 60 days after the date of discharge from the hospital Day Care Expenses (As per our Day Care List) Ambulance Charges - Up to 1% of Sum Insured (maximum 1500) Domiciliary Hospitalization - We will cover Reasonable and Customary Expenses towards Domiciliary Hospitalisation as defined in definition subject to 20% of the Basic Sum Insured or a maximum of up to Rs.20000, whichever is lesser Non Network Hospitalisation Co-pay - For all admissible claims where treatment is taken at hospitals/nursing homes which are not in the list of network hospitals empanelled by the Us/Administrator, insured person shall bear 10% of the eligible admissible claim. Q.9 What does the policy not cover? Ans: SBI General does not cover the following: i) Pre existing Diseases Exclusion: Benefits will not be available for any condition, ailment or injury or related condition(s) for which Insured has been diagnosed, received medical treatment, had signs and / or symptoms, prior to inception of this policy, until 48 consecutive months have elapsed, after the date of inception of this Policy with SBI General. This Exclusion shall cease to apply if Insured Person has maintained this Health Insurance Policy with SBI General for a continuous period of a full 4 years, without break from the date of Insured s first year of this Policy with SBI General. This Exclusion shall also apply to the extent of the amount by which the limit of indemnity has been increased if the Policy is a renewal with SBI General without break in cover. 1 Q.3 What is hospitalisation? Ans: Hospitalisation means insured getting admitted to the hospital for more than 24 hrs for the treatment of any accident, illness, disease or adverse health condition. Q.4 What are the Sum Insured options available under the policy? Ans: Sum Insured options available under the policy range from Rs.100,000 to Rs.500,000 in multiples of 100,000. ii) Exclusions applicable to first 30 days of cover from commencement of Policy: SBI General shall not be liable to make any payment under this Policy in connection with or in respect of Insured Person s hospitalisation due to sickness / illness arising within the first 30 days of the commencement of the Period of Insurance. However, this exclusion will not apply to 2

3 3 iii) hospitalization for any accidental bodily injury occurring during the policy period. This exclusion shall apply also to the extent of the amount by which the limit of indemnity has been increased if the Policy is a renewal of this Health Insurance Policy with SBI General without break in cover. Exclusions applicable to first year of cover from commencement of the Policy, for the following diseases/illness and its related complications including the add ons opted under the policy: Any types of Gastric or Duodenal Ulcers; Tonsillectomy; Adenoidectomy; Mastoidectomy; Tympanoplasty; Surgery on all internal or external tumor/cysts/nodules/polyps of any kind including breast lumps; All types of Hernia and Hydrocele; Anal Fissures, Fistula and Piles; Cataract; Benign Prostatic Hypertrophy; Hysterectomy / Myomectomy for Menorrhagia or Fibromyoma or Prolapse of Uterus; Hypertension, Heart Disease and related complications; Diabetes and related complications; Non infective Arthritis, treatment of Spondylosis / Spondylitis, Gout & Rheumatism; Surgery of Genitourinary Tract; Calculus Diseases; Sinusitis, Nasal disorders and related disorders; Surgery for prolapsed intervertebral disc unless arising from accident; Vertebro-spinal disorders (including disc) and knee conditions; Surgery of varicose veins and varicose ulcers; Chronic renal failure; Medical Expenses incurred in connection with Joint Replacement Surgery due to degenerative condition, age related Osteoarthritis and Osteoporosis unless such Joint Replacement Surgery unless necessitated by accidental bodily injury. This exclusion shall apply also to the extent of the amount by which the limit of indemnity has been increased if the Policy is a renewal of this Health Insurance Policy with SBI General without break in cover for at least 1 year. iv) Treatment outside India. v) Epidemics recognized by WHO or/and Indian Government, Government Screening Programs, etc. vi) vii) viii) ix) War, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, commotion, unrest, rebellion, revolution, insurrection, military or usurped power or confiscation or nationalisation or requisition of or damage by or under the order of any government or public local authority. Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials. Circumcision unless necessary for treatment of a disease, illness or injury not excluded hereunder, or, as may be necessitated due to an accident. Cosmetic or aesthetic treatments of any description, treatment or surgery for change of life/gender, Lasik treatment for refractive error. Any form of plastic surgery (unless necessary for the treatment of illness or accidental bodily injury). x) The cost of spectacles, contact lenses, hearing aids, crutches, wheelchairs, dentures, artificial teeth and all other external appliances, and/or devices unless specifically covered. xi) xii) xiii) xiv) xv) xvi) xvii) Expenses incurred on items for personal comfort like television, telephone, etc. incurred during hospitalization and which have been specifically charged for in the hospitalisation bills issued by the hospital/nursing home. External medical equipment of any kind used at home as post hospitalisation care including cost of instrument used in the treatment of Sleep Apnoea Syndrome (C.P.A.P), Continuous Peritoneal Ambulatory Dialysis (C.P.A.D) and Oxygen concentrator for Bronchial Asthmatic condition. Dental treatment or surgery of any kind unless required as a result of Accidental Bodily Injury to natural teeth requiring hospitalization treatment. Convalescence, general debility, Run-down condition, rest cure, Congenital external illness/disease/defect. All kinds of Congenital internal disease/illness/defects. Intentional self-injury (including but not limited to the use or misuse of any intoxicating drugs or alcohol) and any violation of law or participation in an event/activity that is against law with a criminal intent. Any complications arising out of or ailments requiring treatment due to use or abuse of any substance, drug or alcohol and treatment for de-addiction. xviii) Any condition directly or indirectly caused by or associated with Human Immunodeficiency Virus or Variant/Mutant Viruses and or any syndrome or condition of a similar kind commonly referred to as AIDS. 4

4 5 xix) xx) xxi) xxii) Venereal disease or any sexually transmitted disease or sickness. Treatment arising from or traceable to pregnancy childbirth, miscarriage, abortion or complications of any of this, including Caesarian section. However, this exclusion will not apply to abdominal operation for extra uterine pregnancy (Ectopic Pregnancy), which is proved by submission of Ultra Sonographic Report and certification by Gynecologist that it is life threatening. Any fertility, sub fertility or assisted conception operation or sterilization procedure and related treatment. Vaccination except as part of post-bite treatment for animal bite. xxiii) Vitamins, tonics, nutritional supplements unless forming part of the treatment for injury or disease as certified by the attending Medical Practitioner. xxiv) Surgery to correct Deviated Nasal Septum and Hypertrophied Turbinate unless necessitated by an accidental body injury and proved to our satisfaction that the condition is a result of an accidental injury. xxv) Treatment for any mental illness or psychiatric or psychological ailment/condition. xxvi) Medical Practitioner s home visit expenses during pre and post hospitalization period, attendant Nursing expenses. xxvii) Outpatient Diagnostic, Medical and Surgical procedures or treatments, non-prescribed drugs and medical supplies, hormone replacement therapy, sex change or treatment which results from or is in any way related to sex change. xxviii) Any treatment required arising from Insured s participation in any hazardous activity including but not limited to all forms of skiing, scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc unless specifically agreed by the Insurer. xxix) Genetic disorders and stem cell implantation/surgery/storage. xxx) Expenses incurred at Hospital or Nursing Home primarily for diagnosis irrespective of 24 hours hospitalization. This would also include stay in a hospital without undertaking any treatment or where there is no active regular treatment by the Medical Practitioner, which ordinarily can be given without hospitalization. xxxi) Treatments in health hydro, spas, nature care clinics and the like. xxxii) Treatments taken at any institution which is primarily a rest home or convalescent facility, a place for custodial care, a facility for the aged or alcoholic or drug addicts or for the treatment of psychiatric or mental disorders; even if the institution has been registered as a hospital or nursing home with the appropriate Authorities. xxxiii) Treatment with alternative medicines like Ayurvedic, Homeopathy, Unani, Acupuncture, Acupressure, Osteopath, Naturopathy, Chiropractic, Reflexology and Aromatherapy unless specifically covered under the policy. xxxiv) Hospitalization primarily for investigation purposes, diagnosis, x-ray examination, general or routine physical or medical examinations, not incidental to treatment or diagnosis of a covered disease or illness or any treatment which is not medically necessary and any preventive treatments, or examinations carried out by a Medical Practitioner. xxxv) xxxvi) Hospitalization for donation of any body organs by an Insured Person including complications arising from the donation of organs. Treatment for obesity, weight reduction or weight management. xxxvii) Experimental and unproven treatment. xxxviii) Costs of donor screening or treatment including organ extraction, unless specifically covered and specified in the schedule of the policy. xxxix) xxxx) Disease / injury illness whilst performing duties as a serving member of a military or police force. Any kind of Service charges, Surcharges, Admission fees / Registration charges etc. levied by the hospital. Q.10 Whether the police, para military, defence personnel can be covered? Ans: Yes, but subject to exclusion stated in the Certificate of Insurance that the policy shall not cover War, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, commotion, unrest, rebellion, revolution, insurrection, military or usurped power or confiscation or nationalisation or requisition of or damage by or under the order of any government or public local authority. Q.11 Do we have No Claim Bonus facility on renewal under this policy? Ans: As we are offering a Group Health policy to SBI Account holders, No Claim Bonus is not available under this policy. Q.12 Is portability of existing Health policy allowed under this policy? Ans: As we are offering Group Health policy to SBI Account holders, there is no provision of Portability under this policy. In case any bank customer insists on 'Portability' or the benefit of 'NCB' (5% Sum Insured hike in case of claims free year) then he can be referred to the nearest SBI General branch. SBI General can offer Retail Health product to such customers as it certainly covers 'Portability' as well as 'NCB' benefit. Bank Health product is on a 'group' platform on which Portability and NCB cannot be extended. Q.13 In case age slab of an individual changes during renewal of policy how will the premium be calculated? Ans: In case age slab of an individual changes under individual policy or age slab of 6

5 senior most member changes under Floater policy during subsequent renewal of policies the premium slab under new age would be calculated for computing the premium. Q.14 Where will the policy wording be available? Ans: It is available on SBI General s website For full coverage please refer the policy number in the Certificate and check the policy with the same number available on the website. any of the parents needs to be SBI Account holder. Subject to maximum entry age of 65 years. Q.21 In case a child crosses the age of 18 years during a policy period how is the premium computed at the time of next renewal? Ans: In case a child crosses the age of 18 years he would be considered as an adult and premium will be charged accordingly depending on the plan i.e. Individual / Floater plan that he opts for from the next renewal. Q.15 Whether cover is available for all contingencies mentioned in the policy? Ans: The policy is a common product approved by the regulator which lists all the covers available under Group Health Insurance. The cover applicable to this insurance is mentioned in the Schedule/Certificate of Insurance of the policy. Please read the Schedule/Certificate of Insurance of the policy available on the website and Certificate of Insurance issued to you for the applicable cover to this insurance. Q.16 In case of any pre existing disease can the SBI Account holder enhance his Sum Insured under this policy after 4 years? Ans: SBI Account holder can opt for higher Sum Insured at the time of policy renewal but the enhanced Sum Insured can be applied for pre existing diseases only after completion of the waiting period of 4 years. e.g. customer takes 1 lac Sum Insured and has pre existing disease and after 4 years customers wants to increase the Sum Insured to 5 lacs. In this case the eligibility for hospitalization due to pre existing disease would remain 1 lac only while for any other type of hospitalization it would be 5 lacs. Q.17 Is terrorism covered under the policy? Ans: Yes, terrorism is covered under the policy. Q.22 What would customer get after submitting the Proposal Form duly filled and premium is debited to the SBI Account? Ans: Customer will get a tear way acknowledgment which is the bottom part of Proposal Form, from the staff of SBI. He can demand this tear off document from them. Q.23 What is specification of Pre-existing & Specified illness? Ans: Pre-existing Condition means any condition, ailment or injury or related condition(s) for which Insured had signs or symptoms, and/or were diagnosed, and/or received medical advice/treatment within 48 months to prior to the first Policy issued by the Insurer. For detailed list of specified illness not covered kindly refer Exclusions as provided in Q9. Q.24 In case a customer ticks off any pre existing disease in the Proposal Form what would be the process? Ans: As this product is a pre underwritten one all the information provided in the Proposal Form including that of any pre existing diseases would be kept in Underwriting records and form the basis for acceptance of the proposal and claims will be considered treating the pre existing diseases as exclusions under this policy. Q.18 Can customer having this health product opt for SBI General Retail Health policy also or vice versa? Ans: Yes. Any SBI Account holder having SBI Group Health policy can also take SBI General Retail Health policy and vice versa. Q.19 In case customer takes this Group Health policy for SBI customer and next year wants to take SBI General Retail Health policy whether No Claims Benefit (NCB) and Portability would be offered to him? Ans: Customer can opt for SBI General Retail Health policy at the time of renewal of SBI Group Health policy. The continuity benefit in terms of pre existing benefit would be extended to the customer under SBI General Retail Health policy. As NCB is not present in the SBI Group Health policy henceforth it cannot be extended in the first year of taking the SBI General Retail Health policy. Q.25 In case any customer has more than two children? Ans: If a customer is having more than two children they can be covered in separate plans with parents e.g. in case of family of husband, wife and three children two separate policies can be taken with 1 Adult and two children in one policy and 1 adult and one child in other policy. Q.26 Will the premium be the same as contained in the Presentation, for a customer with pre-existing illness? Ans: The premium charged will remain the same as for any regular customer. Q.27 In case a customer gets hospitalized in different state whether same TPA services would be applicable? Ans: The TPA allocated to the customer would provide him services Pan India 7 Q.20 Can we cover parents under this policy? Ans: This policy covers only spouse under two adults plan. In case of any SBI Account holder wanting to cover parents can do so only under a separate policy wherein Q.28 Whether photocopy of Proposal Form is accepted? Ans: Yes, photocopy of the Proposal Form would be accepted by SBI General if a original form is not available at any point of time. 8

6 9 Q.29 In case of a non networked hospital where a customer has been hospitalized in the last month of the policy expiry, and submits the bills post policy expiry, would the claim stand i.e. The event has happened during the policy period but the claim has been made post expiry of the policy? How would such claims be handled? Ans: Yes, claim would be admissible. Only condition to be followed would be in respect to submission of claim documents post discharge with in stipulated time period as specified in policy document. Caution to be taken to submit bills/claim as early as possible post discharge. Q.30 If a person is hospitalized on the 25th of Aug and continues to be hospitalized till 5th Sept, but 30th Aug is the last day of the policy. For how many days can the bills for hospitalization be paid? Ans: Claim is admissible as the date of admission is within policy period and upto Sum Insured available, however insured can't claim for this admission in renewed policy, for example if Sum Insured is exhausted during treatment and renewal is done insured can't claim benefit of remaining amount from renewed Sum Insured available. Q.31 If a client discloses adverse medical history, then would a doctor's certificate be required? Ans: As this product is a pre underwritten one all the information provided in the Proposal Form including that of any adverse medical history will be kept in Underwriting records and claims if any, will be treated on the basis of the merits of the case accordingly. Q.32 What is the time period within which the insured has to lodge a claim after policy expiry and if policy is not renewed, for an incident happening within the policy period? Ans: Intimation has to be given immediately and not later than 48 hours and documents have to submitted within 30 days of discharge from hospital. This period can be extended to 60 days at the discretion of the Insurer based on merits of the case. Insured/Insured person must provide intimation to Insurer immediately and in any event within 48 hours from date of hospitalisation. However, the Insurer at his sole discretion may relax this condition subject to a satisfactory proof/evidence/justification being produced on the reasons for such a delay beyond the stipulated period. The intimation can be sent by Insured/Insured Person through various modes like /telephone/fax/in person/letter or any other suitable mode. Insured/Insured Person will need to submit the required documents for the processing of hospitalisation Claims within 30 days from the date of discharge from the Hospital, however the Insurer at his sole discretion may relax this condition subject to a satisfactory proof/evidence being produced on the reasons for such a delay beyond the stipulated 30 days up to a maximum period of 60 days. Q.33 Is there any tax benefit available under this policy? Ans: Yes. Premium paid towards this Health Insurance policy qualifies for tax rebates under Income Tax Act (Section 80-D). Q.34 Can the policy be cancelled midway? Ans: Yes. In case of no claim under the policy, refund shall be made on short period basis as specified in terms & conditions of the Certificate. Q.35 What happens if a person has multiple accounts with SBI or any associate bank of SBI? Ans: Irrespective of the number of accounts the Insured has with SBI or any associate bank of SBI, he/she is allowed to take only one policy. Multiple policies for the same Insured are disallowed. Q.36 What happens if multiple policies are taken through more than one account with SBI? Ans: Even if multiple policies are taken through one or more than one account with SBI or any associate bank of SBI for any reason, our liability will be restricted to only one Policy with the highest Sum Insured. All other policies shall be deemed as null and void. Premium paid for all such policies by Insured will be refunded after deduction of administrative expenses of Rs.150. Q.37 Do I get my premium back in case I don t make a claim? Ans: No. The premium is not given back if no claim is made under the policy. Q.38 What happens in case a customer terminates his/her account with SBI? Ans: The policy shall continue to be valid for the remaining period of insurance i.e. till expiry of the current policy. Customer can approach SBI General directly on or before renewal date and SBI General will offer the suitable product available with them at that time. Q.39 Are handicapped or disabled persons covered in this policy? Ans: No. They are not covered under this policy. However they can approach SBI General for a separate suitable cover. Q.40 Is animal attack and snake bite excluded under the policy? Ans: No, they are not excluded. Q.41 Many rural branch customers use thumb impression for all their banking transactions. Can the Proposal Form be accepted with their thumb impression? Ans: Yes, the same can be accepted with a valid witness. Q.42 If the client loses the Certificate, can he/she intimate the claim? Ans: Yes. Customer can intimate the claim in absence of Certificate subject to the following conditions: A. Bank s Branch Manager must attest customer s request. B. Customer should provide the SBI Account number to SBI General. 10