Transcript STAR criticare plus

Section I - Regular Hospitalisation Benefits (SIMILAR TO
MEDICLASSIC)
Section II - Payment of lump-sum compensation for
specified Major Illnesses
18 Years – 65 Years Children below 18yrs
can be covered along with at least one
parent
Acceptance subject to medical screening
for persons above 50 years
Sum Insured restricted to Rs.200000/30% COPAY Will be applicable
Following Sub-limits will apply.
DISEASE
COMPANY’S
LIABILITY
(MAXIMUM)
Cerebro Vascular Accident / Cardio
150000
Vascular Disease/Cancer and Breakage
of bones, Renal Complications.
All other major Surgeries
120000
Hospitalization Expenses incurred as an
inpatient for
Sickness/Illness/Diseases
Accident
Room, boarding & nursing charges @ 2% of the
sum insured up-to a maximum of Rs. 4,000/- per
day.
Surgeons, Anesthetist, Consultants and Specialists
fees.
Operation Theatre charges, drugs and medicines
diagnostic materials, cost of pace maker etc.
Emergency Ambulance
- Rs 750/- per
hospitalisation upto maximum of Rs 1,500/- per
policy period.
Pre-hospitalization expenses incurred for a period
of 30 days prior to the date of hospitalization.
Post hospitalization expenses on a lump-sum basis
@ 7% of the actual hospitalization expenses
(excluding room rent and hospital registration
charges), subject to a maximum of Rs 5,000/-
Expenses on Hospitalization for minimum period of 24 hours are admissible.
However, this time limit will not apply for the following procedures
Cataract
Lithotripsy (Kidney stone removal)
Tonsillectomy
 Cutting and draining of peripheral abscess
Cutting and draining of sub-cutaneous abscessLiver Aspiration
Pleural Effusion Aspiration
Sclerotheraphy
Day Care Procedure
SUB LIMIT
CATARACT
Rs. 20,000/- in respect of one eye and
Rs. 30,000/- in the entire policy period
Lithotripsy (Kidney stone removal)
Rs. 20,000/-
Tonsillectomy
Rs. 15,000/-
Cutting and Draining of Peripheral Abscess
Rs. 2,500/-
Cutting and Draining of Sub-Cutaneous
Abscess
Rs.4,000/-
Liver Aspiration
Rs. 2,000/-
Pleural Effusion Aspiration
Rs. 2,000/-
Sclerotheraphy
Rs. 5,000/-
 Lump Sum Payment
 Compensation Payable – 100%
 Major illness/diseases covered :First Diagnosis of Cancer, Chronic Kidney Disease, Brain Tumour,
Undergoing first time - Major Organ Transplant,
Occurrence for the first time of the following medical events:
Cerebro-Vascular Stroke causing Hemiplegia,
Acute Myocardial Infarction resulting in Left Ventricular Ejection
Fraction of < 25%
Established irreversible Coma,
Established irreversible Paraplegia,
Established irreversible Quadriplegia
Lump Sum Compensation under Section 2
Plus
Payment of Hospitalization under Section 1
up to the date of diagnosis of Major Illness
The Major Illness experienced should be the first incidence of that
major illness.
Hospitalisation expenses would be paid only till the date of
diagnosis of the major illness.
Only one lump sum benefit will be payable irrespective of
 No. of policies issued to the insured
 No. of major illness suffered by the insured
Waiting period of 90 days from the date of issuance of policy (for
section 2 benefits)
Minimum Sum Insured - Rs. 2,00,000/-
Maximum Sum Insured - Rs. 10,00,000/The following Sum Insured options are available
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

Rs. 2,00,000/Rs. 3,00,000/Rs. 4,00,000/Rs. 5,00,000/RS. 10,00,000/-
5mnths to
35 yrs
Sum Insured under
each Section (Rs)
36yrs
to
45yrs
46yrs
55yrs
to 56yrs
to
65yrs
66yrs to
70yrs (Only
for Renewal)
200000
3750
4200
6400
7550
11150
300000
5400
6000
8900
11600
16200
400000
7000
7680
12300
15900
21050
500000
8400
9400
15200
19500
25900
1000000
14600
16100
22600
28200
35350
Pre Existing Diseases
Any Disease contracted during first 30 days under Section I and 90
days under Section II.
30% COPY FOR INSURED PERSONS ABOVE 60 YRS AT ENTRY
First Year Exclusions
 Benign prostate hypertrophy
 Hernia, Hydrocele, Fistula in Anus, Piles
 Sinusitis
 Renal stone and Gall stone removal
First Two Years Exclusions
 Cataract
 Hysterectomy following menorrhagia or fibromyoma
 Treatment for Knee and Joint
 Prolapse of intervertibral
 Varicose veins/ulcers
Injury / Disease arising due to War, Invasion, Act of Foreign Enemy,
Warlike operations
Circumcision unless necessary for treatment of a disease
Cost of spectacles and contact lens, hearing aids, walkers, crutches
wheel chairs and such other aids
Dental treatment or surgery
Convalescence, general debility, Run-down condition or rest cure,
congenital (external/internal) disease or defects or anomalies,
sterility, venereal disease, intentional self injury and use of
intoxicating drugs/alcohol
Naturopathy Treatment
Expenses incurred on Lasik Laser or Refractive Error Correction
treatment
Hospital registration charges, record charges, telephone charges
and such other similar charges.
Non Allopathic shall be restricted to 25% of the sum insured subject
to a maximum of Rs. 25,000/- for the entire policy period.
100% Lump Sum payment for critical illness in addition to
hospitalization expenses
Policy will be in force

even after exhausting the full Sum Insured under Section I till the expiry of the
policy or payment of claim under Section 2.

even after payment of claim under Section II till the expiry of the policy
or exhaustion of sum insured under Section 1
Can be renewed as long as no claim under Section 2.
If there is a claim under section 2, the policy can be renewed
under medi-classic or its equivalent excluding the major illness
for which a claim has been made.
Where the renewal is under Medi-Classic or its equivalent the
Major illness cannot be covered even after a waiting period of
48 months
Survival period of 30 days after occurrence of
major disease not applicable
Higher limit for Tonsillectomy.
Maximum sum insured Rs.1000000/Family Discount available of 5% up to 2
members and 10% for more than two members
In case of Network Hospitals
Immediate intimation to the Call Centre (1800 425
2255)
The insured has to send a request for ‘Pre
Authorization Form’ signed by the Doctor in the
Network Hospital
Based on the intimation a field visit will be done by the
Star Doctor
Pre Authorization will be issued to the Hospital
Based on the Pre Authorization and the Report by the
Star Doctor, Cash Less Treatment will be given by the
Network Hospital
In case of Non Network Hospitals
Immediate intimation to the Call Centre (1800 425
2255)
Claim form will be sent to the Insured.
Based on the intimation a field visit will be done by
the Star Doctor
Bills has to be settled by the Insured and will be
reimbursed by Star on submitting the following
documents
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Original Discharge Summary
Main Hospital Bill with Break Up
Investigation Reports with X-Ray Film
Medical Bills with Prescriptions
Criticare plus
Medi classic
The minimum Sum Insured is 200000/- and The minimum sum insured is
the options are 2,3,4,5 & 10 Lacs
Rs.50000/If the age of the person at entry is above 60 No such provision
yrs, sum insured will be restricted to
Rs.200000/- and co-payments & sub limits will
be applicable
Day Care Procedures :
Day Care Procedures :
Tonsillectomy - Rs.15000/Tonsillectomy - Rs.7500/Incision and Drainage of Abscess is bifurcated Incision and Drainage of Abscessinto 2 as Cutting and draining of
Rs1500
1. Peripheral abscess- Rs2500
Colonoscopy available as day care
2. Sub-cutaneous abscess- Rs4000
procedure.
Colonoscopy removed
Available for persons from 18 yrs of age to 65 Available for persons from 5mnths
yrs . Children below 18yrs can be covered if at to 80 yrs
least one parent is covered
Criticare plus
Medi classic
Coverage under 2 sections
Coverage under 1 section
Lump sum payment for major illness
No Lump sum payment.
Criticare plus
Medi premier
The minimum Sum Insured is 200000/- and The minimum sum insured is
the options are 2,3,5 & 10 Lacs
Rs.100000/- maximum sum
insured is Rs.400000/If the age of the person at entry is above 60 No such provision
yrs, co-payments and sub limits will be
applicable
Day Care Procedures :
Tonsillectomy - Rs.15000/Incision and Drainage of Abscess is bifurcated
into 2 as Cutting and draining of
1. Peripheral abscess- Rs2500
2. Sub-cutaneous abscess- Rs4000
Colonoscopy removed
Day Care Procedures :
Tonsillectomy - Rs.7500/Incision and Drainage of AbscessRs1500
Colonoscopy available as day care
procedure.
Available for persons from 18 yrs of age to 65 Available for persons from 26 yrs
yrs
to 75 yrs
Criticare plus
Medi premier
No such provision
The insured should survive for 30 days
after diagnosis of major illness
Major Illness covered are 11
Major illness covered are 3
On payment of lump sum, section 1
benefits will continue till expiry of policy
or exhaustion of sum insured
On payment of lump sum, all benefits
under the policy ceases and the policy
gets automatically cancelled
There is no such restriction.
Benefit Under Section II is restricted to
50% of the Sum Insured under Section I
subject to a maximum of Rs. 2 lacs.

Can this policy issued with 2 different sum
insured for 2 sections ?
 No.
This policy cannot be issued with 2 different
sum insured for 2 sections.

If the sum insured is Rs.3,00,000/-, does this
mean that Rs.3,00,000/- is for each section or
it is 50% for each section?
 It
is Rs.3,00,000/- for each section
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What will happen when there is a claim under
Section 1 ?
 The
policy will continue till exhaustion of sum
insured under section 1 or expiry date of the policy
which ever is earlier
 The policy can be renewed.

What will happen to the policy when there is a
claim under Section 2 ?
 The
policy will continue with Section 1 benefits until
expiry of the policy or exhaustion Section 1 sum
insured .
 Thereafter the policy can be renewed under medi
classic or its equivalent excluding the major illness
for which claim has been made.
 Where the policy is renewed under Medi-Classic the
Major disease for which a claim has been paid
under Section II would be a permanent exclusion

After diagnosis of Major Illness, is there any
minimum survival period for the insured to take
the lump-sum claim ?
 There

is no survival period as in Medi premier.
Is Non-Allopathic treatment covered under the
policy ?
 Yes.
Up to 25% of Sum Insured subject to a
maximum of Rs.25000/- for the entire policy
period.

Is pre-insurance medical screening required for
issuing this policy ?
 Yes.
If the insured person’s age is above 50 yrs,
medical examination is required.

Is there any co-pay clause under the policy ?
 If
the age of the insured person at entry is above
60, the policy is subject to co-pay of 30%

For how many renewals will this co-pay clause
apply ?
 Co-pay
clause will apply for all renewals.

Will the renewal policy have claims loading if there is
a claim under Section 1 ?


Yes. If the claims ratio of the immediately preceding 2
consecutive years exceeds 100%, claims loading as given
below will apply .
Claims Ratio
Loading on Basic Premium
100-125%
20%
126—150%
30%
Above 150%
50%
Will the renewal policy have claims loading if there is
a claim under Section 2 ?

If there is a claim under Section 2, this policy will not be
renewed

Renal Cancer and CVD (MI) are covered under
Major Diseases but they also find place with
sub limits –does this mean that they are
covered under Section I also?
 The
sub-limits and co-payment relating to the
specific diseases are applicable where any
payment is made under Section I ( payments made
up to the point of diagnosis)