family health optima insurance plan (revised)
DESCRIPTION
Revision. Family Health Optima Insurance Plan (revised). Room rent revised Class A and Class B cities redefined Cataract limits revised Portability brought in 101 day-care procedures included Cumulative bonus in lieu of discount Claims Loading removed - PowerPoint PPT PresentationTRANSCRIPT
Revision
Room rent revised Class A and Class B cities redefined Cataract limits revised Portability brought in 101 day-care procedures included Cumulative bonus in lieu of discount Claims Loading removed Automatic replenishment of SI upon
exhaustion of SI
Two tier rating introduced Zone 1 applicable for Mumbai, Delhi
( Delhi city, Noida, Gurgoan,Ghaziabad, Faridabad) and entire Gujarat State will carry a higher rate
Zone 2 applicable for the rest of India will carry a slightly lower rate
Premium variation between the zones is between 4% to 11%
Premium chargeable will be based on the address of the customer
It is mandatory for the operating offices to get the correct and complete address.
Incomplete proposal forms NOT TO BE ACCEPTED
Policy taken with Zone 2 rates and treatment in Zone 1 areas NO co-payment as is the case with other insurance companies
But the difference in premium between the Zones will be recovered (adjusted in the claims)
Medical screening as per the usual practice to continue
New Rs 15lacs option introduced
Bonus eligibility-
Where the previous policy is claims free then the insurance will be renewed under New FHO with the first slab of Bonus as applicable for the expiring sum insured.
Expiring policy FHO 2A+ 2C sum insured Rs 2 lacs Renewed under New FHO Same family Size but SI is Rs 4 lacs No claim under the previous policy Eligible Bonus will be 10% that is
Rs20000/-
This policy is portable. The benefit of continuity will be given
only for 30 Days, PED, FY and F2Yrs exclusion
The sum insured will be limited to the expiring policy sum insured only
BONUS EARNED WITH THE PREVIOUS INSURER WILL NOT BE GIVEN CREDIT
BENEFITSEXISTING
BENEFITSREVISED
Room Rent A Class City
Rs1500/ B Class City Rs 750/ Other s Rs
500/
Room Rent A Class City Rs 5000/ B Class City Rs3000/ Others Rs1000/
BENEFITSEXISTING
BENEFITSREVISED
Less than 24 Hrs treatment at Hospital “Day Care Procedure”
Specific named procedures
Now 101 Procedures allowed
Sum Insured Amount Per Eye Rs
Amount Per Policy Period Rs
Upto Rs200000/ 12000/
Rs 3/4/5 Lakhs Rs 20000/ 30000/
Rs 10 lakhs Rs 30000/ 40000/
EXISTINGREVISED
Average claims ratio of preceding two consecutive years
Loading on Premium %
>100%-125%
30
>125%-150%
50
> 150 % 80
NO CLAIMS LOADING
EXISTING REVISED A discount of 10% is
allowed on renewal of the policy if there is no claim in the immediately preceding year of the policy. This discount is not cumulative
No discount
Automatic Restoration of Sum Insured WHERE THE SUM INSURED IS
EXHAUSTED DURING THE POLICY PERIOD IT IS AUTOMATICALLY TOPPED UP BY 50% FOR SUM INSURED OF RS 3 LACS AND BY 100% FOR SUM INSURED ABOVE RS 4 LACS AND ABOVE
Sum Insured %of restoration on the Basic Sum Insured
Up to Rs 2 Lakhs Nil
Rs 3 Lakhs 50%
Rs 4 and above
100%
SUCH REPLENISHED AMOUNT SHALL NOT BE UTILISED FOR ANY AILMENT FOR WHICH CLAIM HAS BEEN MADE
Let us assume a family of 2A + 1C has taken a policy for Rs 300000/-
1A is hospitalised for ailment (say for example Hernia) and the entire sum insured of Rs 300000/- is exhausted.
Now the restoration clause will operate and a sum of Rs 150000/- will now be available for the remaining policy period only and no additional premium is chargeable for this
This Rs 150000/- can be utilised by the same person 1A for any ailment unrelated to Hernia. Other persons under the policy can also utilise the sum insured until policy expiry date.
BonusFor every claim free year Bonus upto the
scales is allowed.The bonus ranges from 10% to 25% in
the first renewal and additional 5% to 10% for the second renewal.
Basic Sum InsuredRs
I Year IIYear%
III Year%
Maximum Cumlative Bonus %
100000 Nil 10 5 15
200000 Nil 10 5 15
300000 Nil 25 10 35
400000 Nil 25 10 35
500000 Nil 25 10 35
1000000
Nil 25 10 35
1500000
Nil 25 10 35
Year Basic Sum Insured Rs
Claims Rs Bonus in Rs
First Year 300000 Nil Nil
Second Year 300000 Nil 75000
Third Year 300000 Nil 105000
Fourth Year 300000 Nil 105000
In any case the maximum bonus shall not exceed 35% for sum insured of Rs 3 lacs and above and 15% for sum insured below Rs 3 lacs
Bonus will be computed on the basic sum insured
If there is a claim the earned bonus will be reduced by 50%
If there is a claim in the successive year the bonus will become zero
SUM INSURED OPTION-WISE 2 LACS – MAX DIFF RS 2600 IN AGE
BAND-51 TO 55 YRS 3 LACS – RS 2560 4 LACS- RS 2000 5 LACS – RS 3800ALL FOR ZONE 1
EXAMPLE – INSURED 52YRS FAMILY SIZE 2A+ 2C SUM INSURED RS 5 LACS ZONE 2
2 CLAIM FREE YEARS. THE SAVINGS CAN BE USED FOR BUYING A SURPLUS POLICY
SUM INSURED
PREMIUM STAR
MARKET PREM
SAVING
TOTAL COVERAGE INCL BONUS
500000 16075 20474 4399 500000 + 175000=675000
1000000* 4300 675000+1000000=1675000**
*SUPER SURPLUS
** BUT MARKET POL SI WILL BE RS 500000 +BONUS RS500000= TOTAL RS 1000000 ONLY
NO ONE YEAR WAITING PERIOD – MIN WAITING PERIOD IS 2 YRS UNDER POLICY
BONUS; IF THERE IS A CLAIM THE BONUS IS REDUCED BY 50% OF THE BASIC SI.
THAT IS WHAT IS EARNED IS LOST
FOR EG X TAKES A POLICY FOR RS 3 LACS HAS ONE CLAIM FREE YR IN YR 2 HIS COVERAGE AMNT IS RS450000/- IN YR 3 HE LODGES A CLAIM AND IN YR 4
HIS COVERAGE WILL BE ONLY THE BASIC SI OF RS 3LACS
THE BONUS EARNED IS TOTALLY LOST – BUT HE CONTINUES TO PAY THE HIGHER PREMIUM
NOW UNDER OUR POLICY YR 1 POLICY FOR RS 3LACS- NO CLAIM YR 2 HIS COVERAGE IS RS 300000+75000(B) YR 3 THERE IS A CLAIM YR 4 HIS COVERAGE WILL BE 300000+37500
HE CAN HAVE THE CAKE & EAT IT TOO !