Frequently Asked Questions (FAQs)- Health

1. What is health insurance? Why should I opt for it? Or what are the benefits of taking health insurance?

Health insurance covers you and your family against expenses that you may incur on hospitalization as an in-patient in a hospital or nursing home in India for treatment of a disease.

With the rising incidence of diseases and cost of treatment, any illness can mean substantial financial outgo for you and your family. Health insurance allows you to plan for such events without feeling the financial burden of treatment. It also allows tax saving since the premium that you pay on your health insurance policy is eligible for tax deduction under Section 80 D of the Income Tax Act. (Up to Rs.15000 for an individual or Rs.20000 for senior citizen of over 65 years of age)

2. What are the benefits of taking SmartHealth Insurance Policy?

Each insurance company offers different plans for health insurance which cover different benefits. Bharti AXA offers the following:

a. Hospitalisation Expenses including Hospital charges (Room & Boarding and Operation theatre), fees of Surgeon, Anesthetist, Nurses, Specialists, the cost of diagnostic tests, medicines, blood, oxygen, appliances like pacemaker, artificial limbs and organs etc

b. Domiciliary Hospitalisation covers payment of expenses towards medical treatment for a period exceeding three days for disease, illness or injury, which in the normal course, would require hospitalisation, but is actually taken at home in India.

c. Day Care Treatment wherein 24 hours hospitalization is not required, due to advanced technological treatments/procedures being available

d. Pre and Post Hospitalisation expenses covers relevant medical expenses for a specified period incurred before & after hospitalisation for disease / illness / injury sustained and considered a part of a claim admissible under the Policy.

e. Pre-existing diseases are covered from the 5^th year onwards, after four years of continuous coverage with us.

f. Critical Illness where a separate and additional Sum Insured is available, exclusively for treatment of defined critical illnesses. We cover a total 20 critical illnesses - The customer has an option to opt for coverage of critical illnesses either on reimbursement basis or on lumpsum benefit basis.

g. Dread Disease Recuperation - An allowance Payment towards Recuperation expenses incurred post discharge from the Hospital, in case the Insured contracts any of the Critical Illnesses and undertakes treatment for the same in a Hospital as an in-patient and for which a valid claim under the Policy is admissible.

h. Transplantation of Organs - Covers hospitalisation expenses incurred towards donor for a major organ transplant in case the Insured contracts any of the critical illnesses requiring major Organ Transplantation surgery and undergoes surgery and treatment in a Hospital as an in-patient and for which a valid claim under this Policy is admissible.

A host of value-added benefits such as:

• Hospital Cash Allowance
• Home Nursing
• Ambulance Charges
• In-patient Physiotherapy Charges
• Recovery Grant
• Accompanying Person's Expenses
• Parent Accommodation as Companion for Child
• Out-patient Dental Emergency Treatment (arising out of Accident only)
• Out-patient Emergency treatment for accidents
• Children Education Fund
• Mortal Remains

3. Is health insurance mandatory? Or what will happen if I do not apply for this insurance?

Health insurance is not mandatory. It depends entirely on you. If you are covered under health insurance it'll take care of your costs of hospitalization or treatment that would otherwise mean substantial unplanned financial outgo.

4. How do I decide the amount of insurance I require or does the insurance company decide it?

You can decide the amount of insurance on your own. We have a variety of sum insured options for you to choose from. You can decide on the amount based on the number of family members to be covered under the policy, the age of family members, the expected costs of treatment and the amount of premium you are willing to pay.

5. Does the Smart health insurance policy cover losses due to an accident or will I have to take a separate accident policy?

A health insurance policy covers hospitalization expenses or expenses incurred on treatment of injury as a result of an accident whereas a Personal Accident policy provides compensation for loss suffered due to accident. So, for a more comprehensive cover, you need to take both types of policies.

6. Is there an age limit to buy the Smarthealth insurance policy?

All insurance companies prescribe their own age limits for health insurance. In our case, we cover individuals from 3 months to 65 years of age, which can be renewed upto the age of 75.

7. My child is 11months old; can he be insured under a health insurance policy?

If your child is between 3 months - 5 years of age, he can be covered as part of a family floater policy with one or both parents. Once the child is more than 5 years, you can choose between continuing the family floater policy and taking a separate policy for the child.

8. Can all types of entities (minors, residents, NRI’s) be covered under the Smart Health insurance policy?

The Smart Health Insurance policy takes care of your hospitalization expenses in India. All residents of India, who are aged over 3 months of age upto 65 years can be covered under the Health Insurance plan.

9. Can parents be covered under my Health insurance policy?

We cover self, spouse and two dependent children below the age of twenty one years under one policy. However, for parents, you can take a separate policy.

10. What is the minimum / maximum amount of sum insured that I can opt for?

The minimum amount of sum insured is Rs. 50,000 for an individual and Rs. 1 lakh for a floater plan. The maximum amount is upto 5 lakhs.

11. What are pre & post hospitalization?

Pre and post hospitalization means the medical expenses incurred during a period before & after hospitalisation for any disease / illness / injury sustained which is covered under your Policy. The period before and after hospitalization that is covered depends on the type of plan opted for. We have three different plans to choose from – Basic, Premium and Optimum. In case of Basic Plan, pre-hospitalisation expenses and post-hospitalization expenses are covered for a period of upto 30 days before hospitalization and upto 60 days after hospitalization respectively. In case of Premium Plan, pre-hospitalisation expenses and post-hospitalization expenses are covered for a period of upto 45 days before hospitalization and upto 60 days after hospitalization respectively. In case of Optimum Plan, pre-hospitalisation expenses and post-hospitalization expenses are covered for a period of upto 60 days before hospitalization and upto 90 days after hospitalization respectively.

12. What is recovery grant?

Recovery grant is a lump sum payment made to the insured person as compensation in case the Insured is hospitalized for more than 8 consecutive days. A lump sum benefit of Rs. 12, 500 is paid under the Optimum Plan.

13. What is cashless facility?

Cashless claims facility is available in our network of tied-up hospital where we settle claims directly with the hospital / nursing home without you having to pay any amount to the hospital directly. The way it works is that in the case of pre-planned hospitalization, if the chosen hospital is included in our network of cashless hospitals, you need to send us a claim form along with certification from the doctor about the nature of illness and treatment. Once our Third Party Administrator receives the information, and if the claim is admissible, the TPA sends you a pre-authorisation, in a matter of few hours, for the cashless claim. You can use the cashless facility in this manner. We have more than 4000 network hospitals where you can avail this facility.

14. Are there any taxation benefits if I take health insurance policy?

The premium paid on a health insurance policy is eligible for deduction under section 80D of the Income Tax Act. The amount of deduction available is up to Rs.15000 and an additional Rs.10000 for senior citizens aged above 65 years.

15. What are the various exclusions in the Smart Health Policy?

Some of the exclusions under this Policy are:

• Treatment of asthma, chronic nephritis and nephritis syndrome, gastro-enteritis, diabetes mellitus and insipidus, epilepsy, hypertension, influenza, cough and cold, all psychiatric or psychosomatic disorders, pyrexia of unknown origin for less than 10 days, tonsillitis and URTI, arthritis, rheumatism, as far as domiciliary hospitalisation is concerned.
• Pre-existing diseases / illness / injury / conditions. Benefits will not be available for any condition(s) as defined in the policy, until 48 months of continuous coverage have elapsed, since inception of the first policy with the Company
• Personal exclusions if any mentioned in respect of any one or more specific insured persons covered. It is understood that provisions of this exclusion shall not be applicable in case policy is renewed with the company for a continuous period of 48 months.
• Any benefit under Critical illness within first 60 days of inception of the Policy for the first year. This exclusion doesn't apply for subsequent renewals with the Company without a break.
• Medical expenses incurred for treatment undertaken for disease or illness and/or for critical illness within 30 days of the inception date of this Policy. This exclusion doesn't apply for subsequent renewals with the Company without a break.
• Treatment of Cataract, Benign Prostatic Hypertrophy, Myomectomy, Hysterectomy or menorrhagia or fibromyoma unless because of malignancy, Dilation and curettage, Hernia, hydrocele, congenital internal disease, fistula in anus, sinusitis, Skin and all internal tumors/ cysts/nodules/ polyps of any kind including breast lumps unless malignant /adenoids and hemorrhoids, Dialysis required for chronic renal failure, Gastric and Duodenal ulcers and Joint Replacement surgeries unless necessitated by accident during the first two years of the operation of the Policy. However, this exclusion doesn't apply for subsequent renewals with the Company without a break.
• Circumcision unless necessary for treatment of a disease, illness or injury treatment of which is not excluded hereunder or due to an accident.
• Dental treatment or surgery of any kind unless requiring hospitalisation.
• Birth control procedures, hormone replacement therapy, treatment arising from or traceable to pregnancy, childbirth including caesarean section and voluntary medical termination of pregnancy during the first 12 weeks from the date of conception. However, this exclusion will not apply to Ectopic Pregnancy proved by diagnostic means and certified to be life threatening by the attending Medical Practitioner.
• Routine medical, eye and ear examinations, cost of spectacles, laser surgery, contact lenses or hearing aids, vaccinations and inoculation of any kind, issue of medical certificates and examinations as to suitability for employment or travel.
• Aesthetic treatment, cosmetic surgery and plastic surgery unless necessitated due to accident or as a part of any disease/ illness / injury
• Acquired Immune Deficiency Syndrome (AIDS), AIDS related complex syndrome (ARCS) and all diseases / illness / injury caused by and/or related to HIV.
• Vitamins and tonics unless forming part of treatment for disease, illness or injury.
• Treatment of obesity, general debility, convalescence, run­ down condition or rest cure, congenital external / internal disease/ illness or defects or anomalies, sterility, venereal disease or intentional self-injury and use of intoxicating drugs/alcohol.
• Any treatment received in convalescent homes, convalescent hospitals, health hydros, nature cure clinics or similar establishments.
• Any stay in Hospital without undertaking any treatment or where there is no active regular treatment by the Medical Practitioner
• Prostheses, corrective devices and medical appliances, which are not required intra-operatively or for the disease/ illness/ injury for which the Insured / Insured Person was hospitalised
• Sex change or treatment, which results from, or is in any way related to, sex change.
• Treatment of mental disease / illness, stress, psychiatric or psychological disorders.
• Treatment by a family member and self-medication or any treatment that is not scientifically recognized.
• Treatment from persons not registered as Medical Practitioners under respective medical councils
• Any criminal act.
• War, terrorism and nuclear group of perils.
• Disease / illness / injury whilst performing duties as a serving member of a military or a police force.
• Experimental and unproven treatment.
• Charges incurred primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment.
• Costs of donor screening or treatment, unless specifically covered and specified in the Schedule to this Policy.
• Naturopathy treatment.
• Any treatment received outside India.
• Insured/Insured Person whilst engaging in speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports.
• Insured/Insured Person whilst flying or taking part in aerial activities (including cabin crew) except as a fare-paying passenger in a regular Scheduled airline or air charter company

16. For what time period do you issue a Health insurance policy? Will you issue a policy for more / less than a year & if yes - how will the premium be adjusted?

We issue policies for duration of 1 year or more.

17. Are health cards provided?

We will send you a Health Card along with the policy schedule and 80D certificate, once you take your policy with us. This card can be produced at the time of admission into a hospital for using the cashless facility. A health card mentions the contact details and the contact numbers of the TPA. In case of a medical emergency, you can call on these numbers for queries, clarifications and for seeking any kind of assistance.

Moreover, you need to display your health card at the time of admission into the hospital.

18. Who are the designated TPAs?

Our third party administrators are:

1. E-meditek solutions for any claims in North and East Zones.

2. Paramount Health Services for any claims in South and West Zones.

The break-up of states which fall under the different zones are given below:

19. My employer already covers all medical bills for my family and me. Do I still need Health Insurance?

This facility will be available to you only till you are part of the company. Also, it might be available only to a specific amount. It might not be sufficient when a medical contingency occurs. Hence it would be advisable to go for a health insurance policy.

Your employer will cover your medical expenses only as long as you are in his services. Tomorrow, you may change your job, retire, or even start something on your own. In all such cases you and your family will be stranded if a medical emergency arises and you have not arranged for an alternative health insurance policy. It is at this point of time that Smart Health Insurance policy will come to your rescue. It can act as a supplement to your existing medical cover in case the cost of medical treatment is higher than your existing cover level.

20. Will the health insurance policy cover me in case of any hospitalization abroad?

No, the health insurance policy is meant to cover hospitalization only in India . To cover hospitalization abroad, you need to take a travel insurance policy.

21. What is a floater policy? How is it beneficial to take it?

A family floater policy covers all family members (Insured, his/her spouse and two dependent children upto the age of 23 years) under one single policy. The Sum Insured floats over the entire Family and a consolidated premium needs to be paid.

e.g.: Mr. Sharma, his wife and his two children are covered under a traditional individual health insurance plan - Mr. Sharma has Rs. 2 lac, his wife Rs. 1 lac, their son and daughter Rs.50,000 each and they have paid premium for all these 4 policies. In an unforeseen situation, wherein surgery and post hospitalisation bill of their son amounts to Rs. 1.30 lac. The existing policy will cover only Rs. 50,000, while Mr. Sharma will have to bear the balance Rs. 80,000 from his pocket.

Suppose Mr. Sharma chooses to instead take a Smart Health Insurance Policy for Rs. 34 Lakhs. This Family Floater will cover entire Rs. 1.30 lac medical expenses of Mr. Prakash's son

If I am only admitted in a hospital for less than a day, is the expense still covered?

Sir/Madam, your hospitalization expenses are covered only if you have been hospitalized for a minimum period of 24 hours. However, certain day care treatments, which do not require 24 hour hospitalization, are also covered under our Health Insurance policy. The treatments included are

Dialysis

Chemotherapy

Radiotherapy

Eye surgery

Dental surgery

Lithotripsy (kidney stone removal)

Tonsillectomy

Dilatation & Curettage

Cardiac Catherization

Hydrocele surgery

Herniarepair surgery

Surgeries/procedures that require less than 24 hours hospitalisation due to advancement in technology.

What is domiciliary hospitalization? What do you cover under it?

Domiciliary hospitalization means treatment done at home in India for a period exceeding three days for disease, illness or injury, which in the normal course, would require hospitalization. This could happen if either the condition of the patient is such that he/she cannot be moved to Hospital/Nursing Home, or the patient cannot be admitted to Hospital/Nursing Home for lack of accommodation.

In such cases, we cover the cost of the treatment as well as expenses, if any, on employment of qualified nurses, employed on the recommendation of the attending Medical Practitioner. The cover is limited to a maximum of 10% of the sum insured and will be payable once the treatment exceeds 3 days and it has to be applied for at the time of taking the policy.

What is a critical illness cover?

The critical illness cover takes care of expenses incurred for treatment of any of the specified critical illnesses. The Coverage is available in either of the following options:

• Payment of lump sum benefit amount if the Insured Person is being diagnosed as contracting any of specified Critical Illnesses and surviving for more than 30 days post such diagnosis.
• Payment /reimbursement of expenses incurred for treatment of such specified Critical Illness in a Hospital / Nursing Home

This benefit is available after a waiting period of 60 days from the date of inception of the first year Policy

The SI available under this benefit is separate and additional to the SI available under the Hospitalisation benefit Section of the Policy.

The following critical illnesses are covered under the Smart Health Insurance POlicy

• Cancer
• First Heart Attack
• Coronary Artery Disease
• Coronary Artery Bypass surgery
• Heart Valve Surgery
• Surgery to Aorta
• Stroke
• Kidney Failure
• Aplastic Anaemia
• End Stage Lung Disease
• End Stage Liver Failure
• Coma
• Major Burns
• Major Organ/Bone Marrow Transplantation
• Multiple Sclerosis
• Fulminant Hepatitis
• Motor Neurone Disease
• Primary Pulmonary Hypertension
• Terminal Illness
• Bacterial Meningitis

25. I would like to buy a Health Insurance Policy for myself from you. How do I go about it?

You can get in touch with our nearest branch or you can call on our toll free number ? 1800-103-2292 or write to us at customer.service@bharti-axagi.co.in.

If you are aged 45 years or less and do not suffer from any pre-existing conditions/diseases/injuries, you will be able to get your policy instantly. Once the sales representative gets in touch with you, you will need to fill in the proposal form. The sales representative will let you know the premium that you will need to pay. Once you handed over the filled up proposal form and cheque for the premium amount, the sales representative will then activate your policy and hand over your proposal/schedule back to you.

If you are aged more than 45 years and upto 65 years, the sales representative will get in touch with you. You will need it fill in your proposal form. Depending on your age and the plan that you are opting, you might need to go for medical tests. The sales representative will intimate you of the requirement to go for the tests, if so required.  Once we review the medical test reports and underwrite your case, the sales representative will get in touch again. Upon intimation, you can submit the premium cheque and we will process the case and send your policy documents to your doorstep.

26. What kind of tests do you need to be done?

The medical tests that are required to be done will be intimated once the proposal form is filled up and submitted.

27. How is premium calculated on the Smart Health Insurance policy?

The Premium payable on your Smart health Insurance Policy is based on the following factors:

a. The number of family members to be covered under a floater plan

b. The age of the senior most person of the family to be covered under a floater plan

c. The type of policy you opt for - (Basic/Premium/Optimum)

The Sum insured