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S 

Æhe term Insurance, broadly defined, ͞is that of an agreement in which


both parties agree to the sharing of risk. Basically, the client pays a sum
of money called the Premium and in turn the Insurance firm would
commit to pay a predetermined sum of money to meet the customer's
claims. Health insurance will protect you and your dependants against
any financial constraints arising on account of a medical emergency͟.

S

Ôapid population growth, contamination of food, Water and Air etc.
which leads to hospitalization are more frequent. To cater to the
varying and increasing needs, different forms are available. Health
insurance is a safeguard against rising medical costs. A health insurance
policy is a contract between an insurer and an individual or group, in
which the insurer agrees to provide specified health insurance at an
agreed upon price (premium).

Depending upon the policy, premium may be payable either in a


lumpsum or in installment. Health Insurance usually provides either
direct payment or reimbursement for expenses associated with illness
and injuries. The cost and the range of protection depend on the
insurance provider and the policy purchased. The health insurance has
changed the way medicine is dispensed and sold in most part of the
world. In India, its impact has yet to be felt.

c 
However, the introduction of famous ͚MEDICLAIM͛ policy has made a
huge difference to an ordinary citizen͛s usage of insurance for medical
cover purpose. There are many health cancers including the following
which accentuate the demand for health insurance:-

1.cEnvironment pollution is causing serious health problems to


humans.

2.cThe fast spreading AIDS, poisonous gases, various wastes


including nuclear waste generated by the people are seriously
endangering the life on the earth.

3.cA person may face serious monetary problems for the medical
treatment and hospitalization during life.

cccccc¦ 
 like other forms of insurance is a form of
collectivism by means of which people collectively pool their risk, in this
case the risk of incurring medical expenses. It is sometimes used more
broadly to include insurance covering disability or long-term nursing or
custodial care needs. It may be provided through a government-
sponsored social insurance program, or from private insurance
companies. It may be purchased on a group basis (e.g., by a firm to
cover its employees) or purchased by individual consumers. In each
case, the covered groups or individuals pay premiums or taxes to help
protect themselves from high or unexpected healthcare expenses.

By estimating the overall risk of healthcare expenses, a routine finance


structure (such as a monthly premium or annual tax) can be developed,
ensuring that money is available to pay for the healthcare benefits
specified in the insurance agreement. The benefit is administered by a
central organization such as a government agency, private business, or
not-for-profit entity

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cThese facilities are officially available to the entire population either
free or for nominal charges.

cAlong with some other networks of village health workers maternal


and child health programs and specialty disease prevention
programs these public facilities carry out a central role in India͛s
primary health care system.

cStudies have shown that these facilities are mostly underfunded,


understaffed and short of drugs and essential supplies and that they
sometimes suffer from low morale and inadequate motivation.

cMuch of the facilities for health insurance originates from the Union
Ministry of Health and family welfare and is channeled to the state
governments, which retain considerable authority for the spending
decisions.
cÝver the years, the central government has been the main source of
funds for the primary health care facilities, whereas the states bear
the major responsibility of recurrent costs, especially the costs of
running hospitals.

cThis system has added to the overall inefficiency of public health


facilities.


c  
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cThe central government health scheme was introduced in 1954 as a


contributory health scheme to provide comprehensive medical care
to the central government employees and their families.

cIt was basically designed to replace the cumbersome and expensive


system of reimbursements.

cSeparate dispensaries are maintained for the exclusive use of the


central government employees covered by the scheme.

cÝver the years coverage has grown substantially with provision for
the non-allopathic system of medicines as well as for allopathic. In
addition, the CGHS reimburses patients for part of then out of
pocket costs on treatment at the government hospitals and some
other facilities.

c The medical facilities are provided through Wellness Centers


(previously referred to as CGHS Dispensaries) /polyclinics
under Allopathic, Ayurveda, Yoga, Unani, Sidha and Homeopathic
systems of medicines.

1.c248 allopathic dispensaries, 19 polyclinics.78 Ayush


dispensary/ units
2.c3 Yoga Centres ,65 Laboratories ,17 Dental


c *
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cEstablishment in 1948,the Employees State Insurance Scheme is an


insurance system which provided both the cash and the medical
benefits.

cIt is managed by the Employees State Insurance Corporation, a


wholly government owned enterprise.

cIt was conceived as a compulsory social security benefit for workers


in the formal sector.

cThe original legislation creating the scheme allowed it to cover only


factories which have been using power and employing 10 or more
workers.

cHowever since 1989 the scheme has been expanded and it now
includes all such factories which are not using power and employing
20 or more persons.


c X
  
 
c

The following types of policies are issued by the insurance Corporation


in order to meet the requirement of the policy at large:
c

1.cIndividual Mediclaim Policy

2.cBhavishya Arogya Policy

3.cJan Arogya bima Policy

4.cCancer Insurance Policy

5.cGroup Mediclaim Policy


c

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This policy covers the hospitalization and domiciliary hospitalization
expenses for diseases suffered during the policy period. It also covers
hospitalization for injuries caused during an accident.

The following expenses are usually covered under this policy:

a) Boarding expenses in a hospital or nursing home- as per the


description provided in the policy.

b) Surgical fees, anesthetist fees, medical practitioner and consultant's


fees, specialist fees and nursing expenses.

c Ë
d) Ýperation theatre charges, surgical appliances, medicines and drugs,
diagnostic reports, dialysis, chemotherapy charges etc.

cThe total liability covered under such a policy does not exceed the
total sum assured for each such disease as mentioned in the
schedule by the insurer at the time of buying the policy.

cIn Mediclaim reimbursement is not commonly used as a claim


settlement system. It is permitted only when the treatment is
taken at a hospital of that meets the criteria that are prescribed in
the policy.

cIn order to recover the claims under this policy, the claimant
should be hospitalized for a minimum period of 24 hours.
Expenses incurred for a period upto 30 days prior to
hospitalization and 60 days after hospitalization could be
considered as a part of the claim. In case of certain specific
treatment such as chemotherapy, eye surgery, kidney stone
removal, dialysis etc. the 24 hours, limit could be waived if the
insured is discharged before 24 hours by the doctor.

c!
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cThis is a life time policy where the medical benefits are made
available after retirement of the insured.Ýne has to pay the
premiums during the earning period and make provisons for
medical benefits after retirement.Persons in the age group of 22
to 55 years of age are eligible. for this policy.
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c ´
cThe policy provides hospitalization benefits for a lifetime after
retirement age of the insured. The minimum sum to be insured is
Rs.50, 000 and can be increased in multiples of Rs. 10,000 as a
unit. The maximum sum insured is Rs.2 lacs In case of death of
insured before retirement, refund of premium will be at a pre-
determined scale and it is payable to the nominee or the
assignee.
c

c
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cThis policy is meant for the people with limited means of paying
the premium. The sum assured is limited to Rs 5,000 and the
premium is very low as compared to the regular policy.

cIt does not offer any cumulative bonuses as well as check-up


benefits.

c

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cThere are two types of cancer policies offered in India, one is the
group policy issued by the Indian Cancer Society and the other is a
group policy offered to the members of the Cancer Patients Aid
Association. The cover is limited to Rs. 5 lacs in the case of ICS
policy and can go upto Rs 20 lacs in case of CPAA policy.

cBoth policies require a cancer check up prior to taking out the


policy.

c 
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cThis is available to any corporate association, instituions, and


group of people provided they form the minimum number of
persons to be covered under the policy.

cThe premium are payable by group and the individual members of


the group may enter and exit the policy upon their becoming or
ceasing to be the member of the group.
c

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cCumulative bonus and health check-up expenses are not payable


to members of the group in case of group policies.

cGroup discount in premium is available according to scale


depending upon the total number of insured persons covered
under the group policy at the inception of the policy.

cRenewal premium is subject to bonus in case of low claim ratio.

cMaternity benefit extension is available at extra premium of 10%


of the total basic premium.
c

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c

cThis policy is devised in order to make payment of medical


expenses for illness suffered or accidental injuries sustained by
Indians when travelling abroad on work or for a holiday.

cThis policy was introduced in 1984 and modified in 1991 as


Employment and Study Policy. It was fully revised in 1998 and
introduced as VIDESH YATRA MITRA PÝLICY.
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cExpenses incurred for treatment within 90 days of the


manifestation of the injury or disease.

cExpenses for physician's services, hospitalization, medical services


and medical transportation.

cExpenses for physician ordered evaluation, transportation and


necessary medical en-route when the insured is critically injured
and no suitable local medical assistance is available.

cIf an insured person dies outside India, the expenses of air


transport of the remains for repatriation to India or an equivalent
amount for a local burial or cremation in the country where the
death occurred.

c 
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Apollo DKV Insurance Company Limited will provide the insurance


cover detailed in the Policy to the Insured Person up to the Sum Insured
subject to the terms and conditions of this Policy, Your payment of
premium, and your statements in the Proposal, which is incorporated
into the Policy and is the basis of it.
c
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cClaims made in respect of any of the benefits below will be


subject to the Sum Insured and will affect both the entitlement to
a Cumulative bonus and a health check-up.

cIf any Insured Person suffers an Illness or Accident during the


Policy Period that requires that Insured Person͛s Hospitalisation as
an inpatient, then We will pay:
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The Medical Expenses for:


i)c Room rent, boarding expenses,
ii)c Nursing,
iii)c Intensive care unit,
iv)c A Medical Practitioner,
v)c Anaesthesia, blood, oxygen, operation theatre charges, surgical
appliances,
vi)c Medicines, drugs and consumables,
vii)c Diagnostic procedures,

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c The Medical Expenses incurred due to an Illness in the 30 days


immediately before the Insured Person was Hospitalised, provided that:

c Such Medical Expenses were in fact incurred for the same condition for
which the Insured Person͛s subsequent Hospitalisation was required, and

c We have accepted an inpatient Hospitalisation claim under Benefit 1a).

c We will pay the Medical Expenses incurred within the 60 days prior to the
date of Hospitalisation, if we are provided with the following at least 5
days before the Hospitalisation:
Medical documents with all details about the Illness; and the that
And the place of the Proposed Hospitalisation.

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cThe Medical Expenses incurred in the 60 days immediately after the Insured
Person was discharged post Hospitalisation provided that:

cSuch costs are incurred in respect of the same condition for which the
Insured Person͛s earlier Hospitalisation was required, and

cWe have accepted an inpatient Hospitalisation claim under Benefit 1a).

cWe will pay the Medical Expenses in the 90 days immediately after the
Insured Person was discharged if We were provided with the following at
least 5 days before the Hospitalisation:

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The Medical Expenses for a day care procedure or surgery mentioned in the
list of Day Care Procedures in this Policy where the procedure or surgery is
taken by the Insured Person as an inpatient for less than 24 hours in a
Hospital (but not the outpatient department of a Hospital).

  
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c The Medical Expenses incurred by an Insured Person for medical treatment


taken at his home which would otherwise have required Hospitalisation
because, on the advice of the attending Medical Practitioner, the Insured
Person could not be transferred to a Hospital or a Hospital bed was
unavailable, and provided that:

c The condition for which the medical treatment is required continues for at
least 3 days, in which case We will pay the reasonable cost of any necessary
medical treatment for the entire period, and

c If We accept a claim under this Benefit We will not make any payment for
Post-Hospitalisation expenses but We will pay Pre-hospitalisation expenses
for up to 60 days in accordance with b) above, and

c No payment will be made if the condition for which the Insured Person
requires medical treatment is:
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Claims made in respect of any of the benefits below will be subject to the Sum
Insured and will affect both the entitlement to a Cumulative bonus and a
health check-up.
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A daily cash amount will be payable per day if the Insured Person is Hospitalised
in Shared Accommodation in a Network Hospital for each continuous and
completed period of 24 hours if the Hospitalisation exceeds 48 hours, provided
that:

c Ýur maximum liability shall be restricted to the amount mentioned in


the Schedule of Benefits, and

c The days of admission and discharge shall not be counted, and

c This benefit shall not apply to time spent by the Insured Person in an
intensive care unit, and

c We have accepted an inpatient Hospitalisation claim under Benefit


1a).


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The Medical Expenses for an organ donor͛s treatment for the harvesting of
the organ donated, provided that:

i)c The organ donor is the Insured Person͛s blood relative and the organ
donated is for the use of the Insured Person, and

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ii)c We will not pay the donor͛s pre- and post-hospitalisation expenses or
any other medical treatment for the donor consequent on the
harvesting, and
iii)cWe have accepted an inpatient Hospitalisation claim under Benefit 1a).
c


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c We will reimburse the expenses incurred on an ambulance offered by


a healthcare or ambulance service provider used to transfer the
Insured Person to the nearest Hospital with adequate emergency
facilities for the provision of health services following an emergency
(namely a sudden, urgent, unexpected occurrence or event, bodily
alteration or occasion requiring immediate medical attention),
provided that:

c Ýur maximum liability shall be restricted to the amount mentioned in


the Schedule of Benefits, and

c We have accepted an inpatient Hospitalisation claim under Benefit


1a).

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c Note: This benefit is optional and effective only if noted as such in the
Schedule of Benefits:c

c If the Insured Person Hospitalised is a child Aged 12 years or less, We will


pay a daily cash amount for 1 accompanying adult for each complete period
of 24 hours if Hospitalisation exceeds 72 hours, provided that:

c Ýur maximum liability shall be restricted to the amount mentioned in the


Schedule of Benefits, and

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c Note: This benefit is optional and effective only if noted as such in the
Schedule of Benefits:

c We will cover the Medical Expenses of any medically necessary treatment


described at 1)a) while the Insured Person is Hospitalised during the Policy
Period as an inpatient for a Newborn Baby provided that:

c We have accepted a claim under 3a), and

c You have submitted a proposal for the insurance of the newborn baby
within 30 working days after the birth, and We have in Ýur sole and
absolute discretion accepted the same and received the premium sought.

c Newborn Baby means those babies born to You and Your spouse during the
Policy Period Aged between 1 day and 90 days.

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c Claims made in respect of any of the benefits below will not be subject to
the Sum Insured and will not affect either the entitlement to a Cumulative
bonus or a health check-up.

c The benefits below are optional and each is only effective if shown in the
Schedule to be effectiveJ



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c We will pay the Medical Expenses for a delivery (including caesarean


section) while Hospitalised or the lawful medical termination of pregnancy
during the Policy Period limited to 2 deliveries or terminations or either
during the lifetime of the Insured Person, provided that:

c Ë
cÝur maximum liability per delivery or termination shall be limited to the
amount specified in the Schedule of Benefits, and

cWe will pay the Medical Expenses of pre-natal and post-natal expenses per
delivery or termination upto the amount stated in the Schedule of
Benefits, and

cWe will cover the Medical Expenses incurred for the medically necessary
treatment of the new born baby upto the amount stated in the Schedule
of Benefits unless the new born baby is covered under 2e), and

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c If You renew this Policy with Us for 3 consecutive years without a


break, then from the fourth year onwards We will pay 50% of the
reasonable costs of any necessary dental treatment taken from a
Network dentist by an Insured Person who has been covered under
this policy benefit for the previous 3 Policy Years, provided that:

c Ýur maximum liability shall be limited to the amount specified in the


Schedule of Benefits, and

c We will only pay for X-rays, extractions, amalgam or composite


fillings, root canal treatments and prescribed drugs for the same, and

c We will not pay for any dental treatment that comprises cosmetic
surgery, dentures, dental prosthesis, dental implants, orthodontics,
orthographic surgery, jaw alignment or treatment for the
temporomandibular (jaw) joint, or upper and lower jaw bone surgery
and surgery related to the temporomandibular (jaw) unless
necessitated by an acute traumatic injury or cancer.

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c In every third year that an Insured Person is insured without a break


under an Easy Health Policy with Us, We will pay up to 50% of the
actual cost of either:

c Ýne pair of spectacles or contact lenses, or

c A hearing aid, excluding batteries.

Provided that:

i)c If the costs claimed are incurred as Ýutpatient Treatment expenses


then these items must be prescribed by a Network EYE/ENT
specialised Medical Practitioner, and
ii)c Ýur maximum liability shall be limited to the amount mentioned in the
Schedule of Benefits, and
iii)c Under a Family Floater, Ýur liability shall be limited to either one pair
of spectacles or hearing aid per family.



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c Claims made in respect of any of the benefits below will not be subject to
the Sum Insured and will not affect either the entitlement to a Cumulative
bonus or a health check-up.

c If the Schedule shows that the Critical Illness benefit is effective, then We
will pay the Critical Illness Sum Insured as a lump sum in addition to Ýur
payment under 1)a), provided that:

c The Insured Person is first diagnosed as suffering from a Critical Illness


during the Policy Period,

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