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Family Plus
About Family Plus
Family Plus is a unique health insurance plan which provides the most comprehensive health coverage at an affordable price. Family Plus is a Family Floater Plan which is designed especially for large families and it covers up to 19 relationships. Family Plus is a health insurance cover which is simple to buy and easy to understand. The product offers a unique benefit where each insured member of the family will have an individual sum insured apart from a floater sum insured and reload benefit which any of the family member can consume in case of a major illness. This ensures you are adequately covered at all times. It comes with rich no claim bonus which also helps make your insurance inflation proof by adding 20% additional sum insured for each claim free year.
Family Plus will have an individual base sum insured and a common floater sum insured in the same policy.
The customer has to choose one individual sum insured and one floater sum insured from the below available options. The base sum insured has to be the same for all members.
Individual Base Sum Insured - Rs.2 lacs, Rs.3 lacs, Rs.5 lacs, Rs.10 lacs & Rs.15 lacs.
Floater Sum Insured - Rs.3 lacs, Rs.4 lacs, Rs.5 lacs, Rs.10 lacs, Rs.15 lacs, Rs.20 lacs, Rs.25 lacs & Rs.50 lacs.
Key Benefits
19 Different Relations
Coverage for 19 Different Relations in Same Policy
Maternity Benefit with Nutritional Allowance Benefit
Maternity Benefit with Nutrional Allowance Benefit
Individual + Floater Sum Insured
A unique combination of Individual + Floater Sum Insured in the same policy.
Reload Benefit
Reload Benefit doubles your Base Sum Insured at No Extra Cost
No Claim Bonus
Double the Base Sum Insured in 5 Claim-Free years with our accelerated No-Claim Bonus
Age Eligibility
There is No Restriction on Maximum Entry Age
Who Can Be Covered ?
The below given relations can be offered cover in the policy.
Spouse as long as he or she continues to be married to you, Son, Daughter-in-law, Daughter, Father, Mother, Father-in-law as long as your spouse continues to be married to you, Mother-in-law as long as your spouse continues to be married to you, Grand father, Grand mother, Grand son, Grand daughter, Son-in-law, Brother, Sister, Sister-in-law, Brother-in-law, Nephew and Niece.
Coverages
This distinct insurance plan will take care of the medical treatment for critical illnesses, severe medical conditions, or any other serious health condition.
Here is a list of features that are covered and exclusions that are not covered.
Here are the key benefits offered by Family Plus.
- Inpatient hospitalization expenses up to Sum Insured.
- Pre and post-hospitalization expenses repayment up to the amount of sum insured for 60 and 90 days, respectively.
- All day-care procedures up to the sum insured amount.
- Coverage for the treatment of organ donor up to the amount of sum insured.
- Ambulance cover of up to Rs. 4,000, for per event of hospitalization for every insured member.
- No-claim bonus (NCB) starts from 20% of the base sum insured and extends up to 100%. No reduction in NCB, even when a claim is filed during a particular year.
- 100% Re-load of the base sum insured in case the total sum insured and NCB is completely exhausted.
- Vaccination in case of animal bite - Expenses up to Rs.5,000 covered.
- AYUSH Treatment - Inpatient hospitalization cover of the amount up to the sum insured in government hospitals and up to Rs. 30,000 in other hospitals.
- Domiciliary hospitalization expenses covered up to the sum insured amount.
- Second opinion for diagnosis and treatment of 11 specified critical illnesses.
- Emergency domestic evacuation cover of up to Rs. 1 lac.
- Health & Wellness - We will provide various preventive healthcare & wellness related services that will help you to assess your health status and aid in improving your overall wellbeing. These services include health related articles on your registered email Id, doctor on email chat and annual health check-ups for every member more than 18 years old, irrespective of claim.
- Maternity Benefit cover for up to 2 deliveries if 2 adults are covered under the same family floater policy including New Born Baby Cover and Vaccination for New Born in first year
- Nutritional Allowance for mother post discharge after delivery
- Pre-existing medical conditions described in the policy and declared by the insured at the time of purchase will avail cover only after 36 months of continuous policy coverage. No claims will be settled if there is any gap in renewal of policy.
- Diseases that are contracted by the insured person within first 30 days after the commencement of policy will not be considered for claims.
- Diseases such as Cataract, Benign Prostatic Hypertrophy, Knee/Hip Replacement, Chronic Renal Failure/ End Stage Renal Failure etc., will not be covered during first two years of insurance.
- Permanent exclusions include medical cover availed due to Addictive Conditions and Disorders, Adventure or Hazardous Sports, Ageing and Puberty, Alternative Treatment (except AYUSH), Artificial Life Maintenance, Charges for Medical Papers, Circumcision, Conflict and Disaster, Congenital Conditions, Convalescence and Rehabilitation, Cosmetic Surgery, Dental/Oral Treatment, Drugs and Dressing for OPD Treatment or Take-home use, Eyesight Treatment, Health Hydros, Nature Cure, Wellness Clinics, HIV and AIDS, Hereditary Conditions, Hospitalization for Observation or Investigative purpose only, Items of personal comfort and convenience, Psychiatric and Psychosomatic Conditions, Obesity, OPD Treatment, Preventive Care, Reproductive Medicine, Self-inflicted Injuries, Sexual problems and gender issues, Sexually Transmitted Diseases, Sleep Disorders, Speech Disorders, Stem Cell Implantation, Treatment for Alopecia, Treatment for Developmental Problems, Treatment received outside India, Unproven/Experimental Treatment, Treatment from Unrecognized Hospital or Physician, Unrelated Diagnostic, or Injury due to Unlawful Activity.
Family Plus - Claims Procedure
Please review your Family Plus policy and familiarize yourself with policy benefits, terms and conditions and exclusions which will help you during claims.
All claims for 2 benefits - Second Opinion for 11 Critical Illness / Emergency Domestic Evacuation will be serviced through Europ Assistance India Pvt. Ltd.
All claims for benefits other than 2 benefits will be serviced through Paramount Health Services & Insurance TPA Pvt Ltd.
Claim Intimation
1.You should intimate Royal Sundaram atleast 72 hours prior to hospitalization in case of planned hospitalization or within 48 hours in case of any emergency hospitalization
- 24 x 7 Toll Free: 1800-425-6645
- Email: customer.services@royalsundaram.in
2.Provide the following details during intimation:
- Name of the patient (insured person)
- Diagnosis
- Hospital Details – Name, Address, Contact No
- Treating Doctor Details – Name & Contact No
- Date of Hospitalization
- Expected Discharge
Contact Details of Service Provider:
The following 2 benefits are serviced through the below mentioned service provider.
- Second opinion for critical illness.
- Emergency domestic evacuation
Europ Assistance India Pvt Ltd
Star Hub Building No. 2, 7th Floor, Near ITC Maratha Hotel,
Sahar, Andheri East, Mumbai – 400 059
24 hour dedicated landline number is + 91-22-67872035
Email: royalsundaram@europ-assistance.in
Cashless claims will be serviced by the below mentioned TPA:
Paramount Health Services & Insurance TPA Pvt Ltd
Plot No A – 442, Road No28, MIDC Industrial Area,
Wagle Estate, Ram Nagar, Thane West – 400 604.
Contact details: +91-22-66620858
Toll Free Help Line Number – 1800 22 6655
Procedure to avail Pre-Authorization for Cashless facility
1.For any planned hospitalization, kindly intimate to TPA and seek cashless authorization atleast 72 hours prior to the start of the hospitalization.
2.2. For any emergency hospitalization, inform TPA within 48 hours of the hospitalization.
3.3. TPA will check your coverage as per the eligibility and send a cashless authorization letter to the hospital within 3 hours post receipt of complete documents. In case there is any deficiency in the documents sent, the same will be communicated to the hospital within 3 hours of receipt of documents.
4.4. Please pay the non medical and expenses which are not covered to the hospital prior to the discharge.
5.In case the ailment/treatment is not covered under the policy, a rejection letter would be sent to the hospital Within 2 hours
Note:
You are entitled for cashless only in our Network Hospitals, list of which can be referred on our website. Rejection of cashless in no way indicated rejection of the claim.
Contact Details of Service Provider:
The following 2 benefits are serviced through the below mentioned service provider.
- Second opinion for critical illness.
- Emergency domestic evacuation
Europ Assistance India Pvt Ltd
Star Hub Building No. 2, 7th Floor, Near ITC Maratha Hotel,
Sahar, Andheri East, Mumbai – 400 059
24 hour dedicated landline number is + 91-22-67872035
Email: royalsundaram@europ-assistance.in
Cashless claims will be serviced by the below mentioned TPA:
Paramount Health Services & Insurance TPA Pvt Ltd
Plot No A – 442, Road No28, MIDC Industrial Area,
Wagle Estate, Ram Nagar, Thane West – 400 604.
Contact details: +91-22-66620858
Toll Free Help Line Number – 1800 22 6655
Procedure for Reimbursement Claims
1.Please send the duly filled and signed claim form and all the information/documents mentioned* therein to Royal Sundaram within 30 days from the date of discharge. * Please refer to claim form for complete documentation.
2.If there is any discrepancy in the documents/information submitted by you, Royal Sundaram will send the deficiency letter within 7 days of receipt of claim documents.
3.On receipt of the complete set of claim documents, Royal Sundaram will make the payment for the admissible amount (as per Policy Terms & Conditions), along with a settlement letter within 30 days.
4.The payment will be made in the name of the proposer.
5.Claim documents can be sent on:
Health Claims Department
Royal Sundaram General Insurance Co Ltd
Vishranthi Melaram Towers,
No.2/319, Rajiv Gandhi Salai (OMR)
Karapakkam, Chennai – 600097
Contact Details of Service Provider:
The following 2 benefits are serviced through the below mentioned service provider.
- Second opinion for critical illness.
- Emergency domestic evacuation
Europ Assistance India Pvt Ltd
Star Hub Building No. 2, 7th Floor, Near ITC Maratha Hotel,
Sahar, Andheri East, Mumbai – 400 059
24 hour dedicated landline number is + 91-22-67872035
Email: royalsundaram@europ-assistance.in
Cashless claims will be serviced by the below mentioned TPA:
Paramount Health Services & Insurance TPA Pvt Ltd
Plot No A – 442, Road No28, MIDC Industrial Area,
Wagle Estate, Ram Nagar, Thane West – 400 604.
Contact details: +91-22-66620858
Toll Free Help Line Number – 1800 22 6655
Procedure to avail Pre-Authorization for Cashless facility (for Worldwide Emergency Hospitalization)
1.You need to notify the Service Provider within 24 hours of hospitalization.
2.Our Service Provider will evaluate the request and the eligibility of the Insured Person under the Policy and call for more information or details, if required.
3.Our Service Provider will communicate directly to the Hospital whether the request for pre-authorization has been approved or denied.
4.If the pre-authorization request is approved, Our Service Provider will directly settle the claim with the Hospital. Any additional costs or expenses incurred by or on behalf of the Insured Person beyond the limits pre-authorized by the Service Provider shall be borne by the Insured Person.
Contact Details of Service Provider:
The following 2 benefits are serviced through the below mentioned service provider.
- Second opinion for critical illness.
- Emergency domestic evacuation
Europ Assistance India Pvt Ltd
Star Hub Building No. 2, 7th Floor, Near ITC Maratha Hotel,
Sahar, Andheri East, Mumbai – 400 059
24 hour dedicated landline number is + 91-22-67872035
Email: royalsundaram@europ-assistance.in
Cashless claims will be serviced by the below mentioned TPA:
Paramount Health Services & Insurance TPA Pvt Ltd
Plot No A – 442, Road No28, MIDC Industrial Area,
Wagle Estate, Ram Nagar, Thane West – 400 604.
Contact details: +91-22-66620858
Toll Free Help Line Number – 1800 22 6655
Procedure for International Treatment for 11 specified Critical Illness
1.In the event of the diagnosis of a Specified Critical Illness, the Insured Person should call Our Service Provider immediately and in any event before the commencement of the travel for treatment overseas, on the helpline number specified in the Schedule of Insurance Certificate requesting for a pre-authorization for the treatment.
2.• Our Service Provider will evaluate the request and the eligibility of the Insured Person the Policy and call for more information or details, if required.
3.Our Service Provider will communicate directly to the Hospital and the Insured Person whether the request for pre-authorization has been approved or denied.
If the pre-authorization request is approved, Our Service Provider will directly settle the claim with the Hospital. Any additional costs or expenses incurred by or on behalf of the Insured Person beyond the limits pre-authorized by the Service Provider or at any Non-Network Hospital shall be borne by the Insured Person.
Contact Details of Service Provider:
The following 2 benefits are serviced through the below mentioned service provider.
- Second opinion for critical illness.
- Emergency domestic evacuation
Europ Assistance India Pvt Ltd
Star Hub Building No. 2, 7th Floor, Near ITC Maratha Hotel,
Sahar, Andheri East, Mumbai – 400 059
24 hour dedicated landline number is + 91-22-67872035
Email: royalsundaram@europ-assistance.in
Cashless claims will be serviced by the below mentioned TPA:
Paramount Health Services & Insurance TPA Pvt Ltd
Plot No A – 442, Road No28, MIDC Industrial Area,
Wagle Estate, Ram Nagar, Thane West – 400 604.
Contact details: +91-22-66620858
Toll Free Help Line Number – 1800 22 6655
FAQs
Key features of Family Plus are as mentioned below:
Coverage for 19 different relations in the same policy.
- Legally married spouse as long as he or she continues to be married to You
- Son
- Daughter-in-law
- Daughter
- Father
- Mother
- Father-in-law as long as Your spouse continues to be married to You
- Mother-in-law as long as Your spouse continues to be married to You
- Grandfather
- Grandmother
- Grandson
- Granddaughter
- Son-in-law
- Brother
- Sister
- Sister-in-law
- Brother-in-law
- Nephew
- Niece
1. A unique combination of Individual SI+ Floater SI in the same policy.
2. No upper age limit for enrolment in policy.
3. Access best class healthcare facilities with no capping in terms of Room Rent, disease specific sublimits, etc
4. Cashless hospitalization across 5000+ network hospitals across India
5. Easy documentation and hassle free claim settlement
6. Zonal Pricing depending upon the location of your stay. Pay less if you do not stay in Metro Cities and Gujarat State.
| Product Benifits | ||
| Sum Insured (SI) INR(1) | Individual Base Sum Insured | 2 lacs | 3 lacs | 5 lacs | 10 lacs | 15 lacs |
|---|---|---|
| Floater Sum Insured | 3 lacs | 4 lacs | 5 lacs | 10 lacs | 15 lacs | 20 lacs | 25 lacs | 50 lacs | |
| BASELINE COVER(2)(3) | Inpatient Care | Covered up to Sum Insured |
| Pre And Post Hospitalisation Expenses | 60/90 days, Covered upto Sum Insured | |
| All Day Care Procedures | Covered up to Sum Insured | |
| Organ Donor Expenses | Covered up to Sum Insured | |
| OTHER BENEFITS | Ambulance Cover | Up to INR 4,000, per event of hospitalization for every insured member |
| No-Claim Bonus | 20% of Base Sum Insured up to a max of 100% | |
| Re-load of Sum Insured(4) | Up to Base Sum Insured, once during the policy year | |
| Vaccination in case of Animal Bite(5) | Upto INR 5,000 | |
| Ayush Treatment(6) | Government Hospitals – Covered upto Sum Insured Other Hospitals – Covered upto Rs. 30,000 | |
| Domiciliary Hospitalisation(7) | Covered up to Sum Insured | |
| Second Opinion for 11 specified CriticalIllness(8) | Available Once During The Policy Year | |
| Emergency Domestic Evacuation (Bed To Bed on Advise of Treating Doctor) | Covered up to INR 100,000 | |
| HEALTH & WELLNESS | Health Check - up | Annual |
| Preventive Healthcare & Wellness(9) | Available | |
| MATERNITY BENEFITS | Maternity Cover for up to 2 Deliveries(10) | INR 50,000 |
| New Born Baby Cover | Base SI of mother | |
| Vaccinations for New Born Baby in the first Year(#) | Up to INR 10,000 | |
| Nutritional Allowance for Mother post discharge(11) | Up to INR 10,000 | |
| CUSTOMER LEVEL OPTIONS | Hospital Cash (For 30 Days in case of Hospitalisation Beyond 2 Days) | INR. 2,000 per day |
Key Notes:
(1) It is mandatory to choose 1 base sum insured & 1 floater sum insured. The chosen base sum insured will be same for all covered members.
(2) Baseline cover includes
- 36 month waiting period for pre-existing conditions.
- 2 year waiting period for specific 17 diseases/conditions.
- 30 day Initial waiting period from inception.
- Entry age for adults is 18 years onwards and children is from 91 days onwards. New born Children can be added to existing policies at renewal.
- Zone 2 is priced 15% lower than zone 1 (For eg, if Zone 1 is priced as Rs.100, then zone 2 will be priced at Rs. 85)
- Indicative list of day care procedures has been given in the policy document.
(3) Option of applying Disease specific loading or Co-pay for certain chronic diseases as a part of medical
underwriting.
(4) Re-load of Sum Insured - Reinstate sum insured up to base sum insured. Applicable for different illnesses. Reload will be triggered only once in a policy year and only after the base SI + Floater SI is exhausted. The reloaded SI can be jointly or severally used by all insured members, up to the available limit.
(5) Vaccination for Animal Bite (Post Bite Treatment) - OPD Benefit up to defined limit as part of Overall limit.
(6) AYUSH Treatment - Inpatient Treatment taken up in authorised Government Hospitals.
(7) If due to your health condition you cannot be moved to a hospital or a bed is not available in hospital, we will reimburse the medical expenses incurred for treatment taken at home as long as it involved medical treatment for a period exceeding 3 days.
(8) 2nd Opinion for following critical illnesses are covered: Cancer, First Heart Attack, Open Chest CABG, Open Heart Replacement or Repair of Heart Valves, Coma, Kidney Failure, Stroke, Major Organ/Bone Marrow Transplant, Permanent paralysis of Limbs, Motor Neuron Disease & Multiple Sclerosis.
(9) Preventive Healthcare & Wellness Benefit to offer various health related articles on your registered email Id and doctor on email chat.
(10) Maternity Benefit - Covers up to 2 deliveries if at least 2 adults are covered under the same policy. 24 month waiting period applies to maternity cover including all attached new born baby cover benefits.
(#) - Vaccinations would be covered till the next policy anniversary after which the new born baby has to be included in the policy for the coverage to continue.
(11) Nutrition allowance covers cost of nutritional food supplements & medicines which inter alia includes food supplements advised by medical practitioner for nutrition enriched diet viz calcium tablets, vitamins, tonics, fresh/dry fruits & vegetables to be given to mother post birth of child to recuperate. Fixed benefit payable in the form of a postdated cheque, 2 months after delivery. This is a first of its kind offering in the health insurance industry.
Note: Policy offers a combination of individual sum insured and floater sum insured in the same policy. Minimum 2 members need to be covered in the policy. The following relations of the proposer are allowed to be covered in the policy.
Spouse as long as he or she continues to be married to you, Son, Daughter-in-law, Daughter, Father, Mother, Father-in-law as long as your spouse continues to be married to you, Mother-in-law as long as your spouse continues to be married to you , Grandfather, Grandmother, Grandson, Granddaughter, Son-in-law, Brother, Sister, Sister-in-law, Brother-in-law, Nephew and Niece.
Customer has the option to choose from a wide range of Sum Insured's available as under:
| Type of Sum Insured | Sum Insured |
| Individual Sum Insured | Rs.2 lacs, Rs.3 lacs, Rs.5 lacs, Rs.10 lacs, Rs.15 lacs |
| Floater Sum Insured | Rs.3 lacs, Rs.4 lacs, Rs.5 lacs, Rs.10 lacs, Rs.15 lacs, Rs.20lacs, Rs.25 lacs, Rs. 50 lacs |
Organ Donor Expenses covers the expenses incurred on the hospitalization of the organ donor. All inpatient care expenses related to organ donor are covered, provided:
- He fulfils the Transplantation of Human Organs Act,1994 and other applicable laws.
- The organ donated is used by the insured person.
- A claim is filed for inpatient care by the insured.
If you ever exhaust your health cover due to claims in a given year and there is a further claim either by you for a different illness or your insured family member, we will reload the entire Individual sum insured of your policy at no extra cost. Reloaded sum insured will help you to settle those claims.
We will provide a Re-load equal to 100% of Individual Sum Insured of any one Insured Member. Re-load benefit will be applicable as under:
a) the Individual Sum Insured, No Claim Bonus (if any) and Floater Sum Insured is exhausted as a result of previous claims in that Policy Year; AND
b) The Re-load Sum Insured shall be activated in following conditions:
- Re-load can get activated for same Insured Member in the same Policy year for different illness/injury other than the illness/injury for which claim has already been paid in the current Policy year and/or;
- Re-load can get activated for different Insured Member in the same Policy year
- Re-load benefit once activated for any one of the Insured Member and can be used jointly or severally.
- Re-load once activated for any one of the Insured Member will not get activated again for another Insured Member in the same Policy Year.
c) If the Re-load Sum Insured is not utilised in a Policy Year, it shall not be carried forward to any subsequent Policy Year.
| ZONE | Discount |
| Zone 1 | 0% |
| Zone 2 | 15% |
Note: Proposer address will be an only valid proof for availing benefit under zonal discount.
Family Plus is a medical underwritten product. This being a product offers guaranteed lifelong renewal needs to be medical underwritten at the time of first cover.
Triggers for Medical Underwriting:
We will be having the 5 triggers basis which the case will be decided as STP or Non STP (which will flow into HUMS for further evaluation). The 5 triggers namely are –
- Age – No medicals upto 50 years in Non Banca & upto 60 years in Banca
- Cumulative Sum Insured (Individual Sum Insured + Floater Sum Insured) – Above 10 Lacs above for Non Banca and above 20 Lacs for Banca
- BMI >33
- Answer to any health questions as YES
- Portability – All portability cases will be referred to medical underwriting
The case will flow into HUMS if it triggers one of the above criteria and will be evaluated by a medical doctor.
Suitable medical underwriting handles will be applied to mitigate the risk like
- Copayment
- Loading
- Pre-existing disease
Post the case is referred to Medical Underwriting, Underwriters will ask the customers to undergo the medical tests. Medical tests will be arranged at the nearest center. In last three years, We have conducted tests at almost 35+ unique locations. Hence, we have large network of diagnostic centres for conducting medical tests.
Cost of medical tests will be borne by Royal Sundaram. Home visit can also be arranged for customers but the charges of Home visit will be paid by the customer. Approxi. Cost of home visit will be Rs. 250 and in case of more insured Person in the same house, max. cost of home visit will be Rs. 600.
Two steps of Medical underwriting:
a. Tele underwriting:
We have a team of qualified doctors who calls up customers on their respective contact numbers to know about material information about their medical history, any medicines etc. customers is taking.
Typically, calls to the customers are made between 9.00 am. To 6.00 pm. From Monday to Friday.
Under Family Plus Product, there will be multiple rounds of tele underwriting since it may not be possible for the proposer to possess medical information of all Insured Person(s). example: Son-in-law may not be aware of medicines taken by his mother-in-law.
Post tele underwriting and performing medical tests, there could be counter offer sent to the customers with some loading or co-pay applied on specific 18 conditions listed hereunder.
| Family Plus | |
| 1.Diabetes | 10.Pancreatitis |
| 2.Heart condition | 11.Hyperthyroidism |
| 3.Hypertension | 12.Epilepsy |
| 4.Malignant Cancer | 13.Stroke |
| 5.Rheumatoid Arthritis | 14.Glaucoma |
| 6.Chronic renal failure | 15.Retinal Detachment |
| 7.Peptic Ulcer Disease | 16.Asthma |
| 8.Ulcerative Colitis | 17.COPD |
| 9.Crohns Disease | 18.Arthritis |
Note: Co-pay is applied at Insured level and Loading is applied at policy level. Please note that Royal Sundaram is really scientific in Medical underwriting and any Loading or copay are applied in the form of ICD codes known worldwide. India being a country with big population of Chronic diseases patients and Family Plus is a product where we are able to offer cover to customers with chronic diseases by applying loading/copayment instead od straight away rejection of the proposal.
Grid & tests for Family Plus for Non Banca channels
| Age/Sum Insured | Cumulative SI upto Rs.10lacs | Cumulative SI above Rs.10lacs |
| Upto 50 years | No Check-up | Set1/Set2 |
| 51 years and above | Set 1/Set2 | Set 1/Set2 |
The above grid is valid subject to no adverse declaration. If there is any adverse declaration then the case will move to medical uw in any case and subject to further medical tests. The battery of tests will be selected from the 2 groups – Set1 or Set 2 depending on the doctors assessment post tele uw.
Cumulative sum insured is defined at individual level, which means that if customer opts for 2L individual and 5 L floater then the case will not move for uw as per above grid as at individual level the cumulative SI is <10L (subject to no adverse declaration to health questions). Once the Cumulative SI crosses 10L the case will move to medical uw bucket. If there are 4 members in the family it doesn’t mean that we add the total of all the individual sum insured and the floater to decide whether the case is STP or not. It has to be at individual level.
| Age/Sum Insured | Cumulative SI upto Rs.20lacs | Cumulative SI above Rs.20lacs |
| Upto 60 years | No Check-up | Set1/Set2 |
| 61 years and above | Set 1/Set2 | Set 1/Set2 |
Maternity Expenses: For this benefit, atleast one adult member need to be covered in the policy at the time of first inception under the same Family Floater Policy. We pay Medical Expenses for the delivery of a child, only after 24 months of continuous coverage of mother since the inception of the first Policy with Us. The waiting Period of 24 months will start only after two adults are covered under the policy.
In case, customer is porting from any other policy providing maternity benefit, the respective waiting period served in that policy will be considered as waiting period waiver in Family Plus policy as per portability guideline. Maternity benefits are paid a maximum of Rs. 50,000 per delivery only for two deliveries for each female member covered during the lifetime of the Policy including any of its renewals. However, expenses in respect of harvesting and storage of stem cells are not covered.
Miscarriage will not be payable as a part of Maternity Benefit Claim.
Miscarriage can occur as a result of:
- Accident
- Internal Injury/Sickness/stress
If Miscarriage happens due to an internal injury/sickness/stress, it is not payable. However, it is payable when Miscarriage happens due to an accident.
New Born Baby: The new born baby will be covered as an insured person from birth. We will cover medical expenses towards the medical treatment of the Insured Person’s new born baby while the Insured Person is Hospitalized as an Inpatient for delivery and we have accepted the maternity claim as payable. This benefit is equal to Individual Sum Insured of the mother. Post the expiry of the policy, new born need to be added as a separate member in the policy at the time of renewal.
Vaccination for New Born Baby: We will cover expenses for vaccination of the new born baby upto a limit of Rs. 10,000, if we have accepted the maternity claim as payable. If the Policy Period ends before the New Born Baby has completed one year, then, We will only cover such vaccinations until the baby completes one year, provided that We have accepted the baby as an Insured Person at the time of renewal of the Policy. This benefit is over and above the maternity benefit.
For example: Let us say child birth date is January 2, 2018 and the policy expiry date is April 13, 2018 and vaccination expenses paid till April 13, 2018 is Rs. 3500. Hence, for the rest of the charges to be paid, new born needs to be enrolled at the time of the renewal as a separate member in the policy.
| Time interval | Vaccination to be done (age) # | Frequency |
| Vaccination for first year | ||
| 0-3 months | BCG (From birth to 2 weeks) | 1 |
| OPV (0‚6‚10 weeks) OR OPV + IPV1 (6,10 weeks) | 3 OR 4 | |
| DPT (6 & 10 week) | 2 | |
| Hepatitis-B (0 & 6 week) | 2 | |
| Hib (6 & 10 week) | 2 | |
| 3-6 months | OPV (14 week) OR OPV + IPV2 | 1 OR 2 |
| DPT (14 week) | 1 | |
| Hepatitis-B (14 week) | 1 | |
| Hib (14 week) | 1 | |
| 9 months | Measles (+9 months) | 1 |
| 12 months | Chicken Pox(12 months) | 1 |
Nutrition allowance for mother post discharge a. We will provide Nutrition allowance for mother post-delivery of the child.
b. This benefit is available in the form a fixed benefit and maximum liability under this is Rs. 10,000 and it is payable after a period of 2 months from the date of discharge of mother after delivery of the child.
c. This benefit is payable only if we accept the claim made under the Maternity Benefit. At the time of settlement of Maternity Claim, we shall issue a post-dated cheque of Rs. 10,000 towards Nutritional allowance.
We will cover the cost of health check-up arranged by us through our empaneled service providers as per your plan eligibility defined below: This benefit can be availed at each renewal.
| Annual Health Check-up | List of Medical Tests |
| Complete Blood Count, Urine Routine, ESR, Fasting Blood Sugar, Lipid Profile, Kidney Function Test, ECG, Complete physical examination by Physician |
1. Cataract
2. Stones in biliary and urinary systems
3. Hernia / Hydrocele
4. Hysterectomy for any benign disorder
5. Lumps / cysts / nodules / polyps / internal tumours
6. Gastric and Duodenal Ulcers
7. Surgery on tonsils / adenoids
8. Osteoarthrosis / Arthritis / Gout / Rheumatism / Spondylosis / Spondylitis / Intervertebral Disc Prolapse
9. Fissure / Fistula / Haemorrhoid
10. Sinusitis / Deviated Nasal Septum / Tympanoplasty / Chronic Suppurative Otitis Media
11. Benign Prostatic Hypertrophy
12. Knee/Hip Joint replacement
13. Dilatation and Curettage
14. Varicose veins
15. Dysfunctional Uterine Bleeding / Fibroids / Prolapse Uterus / Endometriosis
16. Diabetes and related complications
17. Chronic Renal Failure or end stage Renal Failure