SHRI RGP GUJARATI

PROFESSIONAL INSTITUTE

RESEARCH REPORT
ON
HEALTH INSURANCE

ACADEMIC SESSION
2022-2023
SUBMITTED TO: SUBMITTED BY
Dr. RAVLEEN KAUR LAXITA LANDE
(Director) MBA (3rd Sem)

Shri Raoji Bhai Gokal Bhai Patel Gujarati Professional Institute

Indore (MP)
 ACKNOWLEDGEMENT

This is very special project brought to fruition through the efforts of

some very special people. I am deeply grateful to all those people
whose enthusiasm and energy transformed my visions of this project
into reality specially to Dr. Ravleen Kaur (Director) because her
commitment and sense of vision moves me and I am indebted to her
for the help and the encouragement.

My writing in this project has also been influenced by no. standard

and popular text book in this field as for as possible, they have been
fully acknowledge at the appropriate places. I express my gratitude
to all of them , I am also deeply grateful to teachers for helping
wherever it required in preparation of this project.

LAXITA LANDE
 Contents

CHAPTER NO. DESCRIPTION

1 INTRODUCTION
2 REASERCH OBJECTIVES
3 BACKGROUND OF HEALTH
INSURANCE IN INDIA
4 TYPES OF POLICIES
5 ADVANTAGES AND DISADVANTAGES
6 DATA ANALYSIS
7 BENEFITS OF FAMILY HEALTH
INSURANCE
8 TYPES OF HEALTH INSURANCE
9 COMPANY AND PRODUCTS
 Introduction

Health insurance is one of the important approaches that can help

in boosting universal healthcare coverage through improved
healthcare utilisation and financial protection. This objectives of
this review are to identify various interventions implemented in
India to promote awareness of health insurance, and to provide
evidence for the effectiveness of such interventions on the
awareness and uptake of health insurance by the resident Indian
population.
The Universal Health Coverage (UHC) is embedded within the
Sustainable Development Goals (SDGs) and aims ‘to ensure healthy
lives and promote well-being for all at all ages by 2030’.It includes
financial risk protection and equal access to quality essential
healthcare services . In other terms, UHC encourages equitable
healthcare and nations across the world are committed to
achieving SDGs through UHC.
Health insurance is one of the important approaches that can help
in boosting UHC through improved healthcare utilisation and
financial protection. There are multiple types of insurance in LMICs
that differ with providers (government vs private sector), scales and
types of beneficiaries. However, in many LMICs, due lack of
acceptability and unwillingness to pay (WTP) premiums, health
insurance coverage is limited. This increases the risk of excluding
vulnerable and at-risk population, who cannot afford to pay health
insurance premium. Additionally, the older adults, and the
individuals with disability and chronic diseases, have less
probability of enrolling in health insurance schemes or their specific
needs may not be covered under the scheme.
RESEARCH OBJECTIVES

Demand for health care and for insurance: We place the potential
customer at the centre of our research interest. We hope to generate
insight into the questions like;
1. What are the indirect (transactional) costs of seeking medical
care?
2. Which institutional arrangement would the clients prefer?
3. What redistribution justice is acceptable to the rural poor?
4. What kind of care do customers prefer (ayurvedic, unani,
allopathic, homeopathic, other traditional), and why?
5. Perception of how individuals can manage risks?
6. what local systems are there?

Supply of healthcare: Nobody is likely to buy health insurance unless

they can expect to get care locally.
1. We shall therefore look at available healthcare supply at each
location.
2. We shall also distinguish suppliers by the type of care they provide
(ayurvedic, unani, allopathic, homeopathic, other traditional), and
assess the fit to priorities of the customers.
3. Additionally, we shall look at sustainable product distribution (e.g.
drugs, perishables), pricing and product development.

Supply of insurance: Extending coverage of insurance, increasing the

number of people insured, contributing to efficiency and stability of
micro health insurance units in India is the overall goal of our work.
To achieve this, questions like
1. How well do the poor understand insurance principles?
2. What is their willingness and ability to pay for health insurance?
have to be answered.
3. How old aged people can be insured?
BACKGROUND OF HEALTH INSURANCE IN INDIA

Launched in 1986, the health insurance industry has grown significantly

mainly due to liberalization of economy and general awareness. According to
the World Bank, by 2010, more than 25% of India's population had access to
some form of health insurance. There are standalone health insurers along
with government sponsored health insurance providers. Until recently, to
improve the awareness and reduce the procrastination for buying health
insurance, the General Insurance Corporation of India and the Insurance
Regulatory and Development Authority (IRDAI) had launched an awareness
campaign for all segments of the population.
Launched in 2007, the National Health Insurance Program (Rashtriya
Swasthya Bima Yojana- RSBY) is led by the Ministry of Health and was
adopted by 29 states in 2014. It is funded 75% by the government and 25%
by the states. The worker and 4 of his dependents benefit from health
insurance if they are not covered by any system and live below the poverty
line. RSBY beneficiaries are required to pay an annual registration fee of ₹30
for hospital coverage up to ₹30,000 per year per family.
On September 25, 2018, the Indian government announced the launch of a
new health insurance for the poorest citizens. Indian Prime
Minister Narendra Modi announced that the new system is expected to reach
more than 500 million people and is called "Modicare". The reform is still in
progress and aims to install universal social security in the country.
The Indian social protection scheme covers insured persons
against risks related to old age, invalidity, death, but also
sickness and maternity, unemployment and finally accident at
work and occupational diseases.

This social protection scheme is not universal and provides only

limited coverage, targeting mainly organized sector's workers
constituting less than 10% of the population in India. All risks are
placed under the supervision of the Ministry of Labour and
Employment.

Social security and health insurance is defined by 5 main texts in

India:

The Employees' State Insurance Act, 1948;

Employees' Provident Funds & Miscellaneous Provisions Act,
1952;
The Employees (Workmen's) Compensation Act, 1923;
The Maternity Benefit Act, 1961;
The Payment of Gratuity Act, 1972;

Social security benefits are mainly managed by: Employees'

State Insurance Corporation (ESIC) and Employees' Provident
Fund Organisation (EPFO)
 TYPES OF
POLICIES
Health insurance in India typically pays for only inpatient
hospitalization and for treatment at hospitals in India. Outpatient
services were not payable under health policies in India. The first
health policies in India were Mediclaim Policies. In Year 2000,
Government of India liberalized insurance and allowed private players
into the insurance sector. The advent of private insurers in India saw
the introduction of many innovative products like family floater plans,
top-up plans, critical illness plans, hospital cash and top up policies.
The health insurance sector hovers around 10% in density
calculations. India is a country with one of the lowest health
insurance penetration, with only 18% of people in urban areas and
14% in rural areas covered under any kind of health insurance
scheme. One of the main reasons for the low penetration and
coverage of health insurance is the lack of competition in the sector.
IRDAI which is responsible for insurance policies in India can create
health circles, similar to telecom circles to promote competition.
In principle, government health services are available to all citizens
under the tax-financed public system. In practice, bottlenecks in
accessing such services compel households to seek private care,
resulting in high out-of-pocket payments.
Health insurance plans in India today can be broadly classified into
these categories:

•Hospitalization

Hospitalization plans are indemnity plans that pay cost of

hospitalization and medical costs of the insured subject to the
sum insured. The sum insured can be applied on a per member
basis in case of individual health policies or on a floater basis in
case of family floater policies. In case of floater policies the sum
insured can be utilized by any of the members insured under the
There is another type of hospitalization policy called a top-up policy.
Top up policies have a high deductible typically set a level of
existing cover. This policy is targeted at people who have some
amount of insurance from their employer. If the employer
provided cover is not enough people can supplement their
cover with the top-up policy. However, this is subject to
deduction on every claim reported for every member on the
final amount payable.

•Family Floater Health Insurance:

Family health insurance plan covers entire family in one health
insurance plan. It works under assumption that not all member
of a family will suffer from illness in one time. It covers hospital
expense which can be pre and post. Most of health insurance
companies in India offering family insurance have good
network of hospitals to benefit the insurer in time of
emergency.

•Pre-Existing Disease Cover Plans:

It offers covers against disease that policyholder had before buying
health policy. Pre-Existing Disease Cover Plans offers cover
against pre-existing disease e.g. diabetes, kidney failure and
many more. After Waiting period of 2 to 4 years it gives all
covers to insurer.

•Senior Citizen Health Insurance:

As name suggest These kind of health insurance plans are for older
people in the family. It provide covers and protection from
health issues during old age. According to IRDAI guidelines,
each insurer should provide cover up to the age of 65 years.
•Maternity Health Insurance:

Maternity health insurance ensures coverage for maternity

and other additional expenses. It takes care of both pre and
post natal care, baby delivery (either normal or caesarean).
Like other insurance, the maternity insurance provider have
wide range of network hospitals and takes care of
ambulance expense.

These services are supervised by the Maternity Benefit Act.

The Maternity Benefit Act applies to women who do not
work in an establishment covered by the ESI but who are
employed in factories, mines, circuses, plantations, shops or
other establishments employing at least 10 persons. Also
covered are women working in an establishment covered by
the ESI, but whose salary exceeds the ceiling of subjection.

Since 2010, the Indira Gandhi Matritva Sahyog Yojana

(IGMSY) program, run by the Ministry of Women and Child
Development, has been set up in some districts (52 in 2017).
This program is intended for pregnant women aged 19 or
over, during their first 2 completed pregnancies (viable
child). The benefit consists of a total amount of ₹6,000 paid
in 3 installments, subject to having performed the obligatory
medical examinations for the mother and the child:

• At the end of 2nd trimester of pregnancy.

• At birth.
• To 6th months of child.
•Hospital daily cash benefit plans:
Daily cash benefits is a defined benefit policy that pays a
defined sum of money for every day of hospitalization. The
payments for a defined number of days in the policy year
and may be subject to a deductible of few days.

•Critical illness plans:

These are benefit based policies which pay a lumpsum
(fixed) benefit amount on diagnosis of covered critical
illness and medical procedures. These illness are generally
specific and high severity and low frequency in nature that
cost high when compared to day to day medical /
treatment need. e.g. heart attack, cancer, stroke etc. Now
some insurers have come up with option of staggered
payment of claims in combination to upfront lumpsum
payment.
•Pro active plans:
Some companies offer Pro active living programs. These are
designed keeping in mind the Indian market and provide
assistance based on medical, behavioural and lifestyle factors
associated with chronic conditions. These services aim to
help customers understand and manage their health better.

•Disease specific special plans:

Some companies offer specially designed disease specific plans
like Dengue Care. These are designed keeping in mind the
growing occurrence of viral diseases like Dengue in India which
has become a cause of concern and thus provide assistance
based on medical needs, behavioural and lifestyle factors
associated with such conditions. These plans aim to help
customers manage their unexpected health expenses better and
at a very minimal cost.
 ADVANTAGES OF
HEALTH INSURANCE
1. Health Insurance Keeps You Financially Protected

As mentioned above, the biggest benefit of purchasing health

insurance is that it prevents erosion of your long-term savings. You
might be saving and investing for goals such as buying a property or
child's education, but you or someone in your family suffering from
a medical emergency can require you to liquidate your assets.

If you are still unable to manage the expenses, you might also go
ahead and borrow money from family, friends, or take a loan. All of
these things can put a huge dent on your current financial health as
well as long-term objectives. Having health insurance can help you
avoid such outcomes due to the rising cost of quality healthcare.

2. Availability of Options

Gone are the days when insurers only used to offer basic health
insurance plans. Modern insurance providers now offer a wide
range of health insurance policies. For instance, most insurers now
offer individual policy and family floater plans. You get to protect
yourself with an individual plan, but with a family floater plan, you
can insure the health of your entire family.

Apart from these two popular options, you can also find other
types of health plans like ULHP (Unit Linked Health Insurance),
critical illness plan, group health insurance, personal accident plan,
and hospital cash benefit plan. The availability of so many options
ensures that you can select a policy that best meets your
requirements.
3. Cashless Hospitalization

One of the biggest benefits of health insurance is cashless claims.

Most top insurers nowadays have an extensive list of network
hospitals all over the country. In case if you are suffering from a
health problem and get admitted to one of the network hospitals,
you’ll mostly be able to take advantage of cashless hospitalisation.

This facility eliminates the traditional claim reimbursement process

where you were first required to clear the hospital dues and then
get it reimbursed from the insurer. With cashless treatment, the
insurer will directly pay your medical bills to the hospital. Thus, you
will not be required to bear the high treatment costs from your
pockets. In case if you are admitted to a non-network hospital, you
will be able to use the reimbursement claim facility here.

4. No Claim Bonus (NCB)

Health insurance plans also come with a bonus element known as

NCB. Health plans are generally renewed every year by paying the
insurance premium. But if you do not file any claim for the entire
year, you will be entitled to receive NCB. This NCB benefit is also
available with vehicle insurance plans. However, there is a major
difference between NCB of vehicle insurance and health insurance.

With motor insurance, the NCB reduces the annual premium. But
with health insurance, the NCB provides you with a higher sum
assured at the same premium amount. So, if the coverage of your
health insurance plan is Rs. 5 lakhs and you do not file any claim in a
year, the coverage will be increased to Rs. 5.5 lakhs (10% of
coverage) in the next year without any increment in the premium
amount.
5.Availability of Add-Ons or Riders

There are also many different types of add-ons available with health
insurance policies. While the add-ons slightly increase the policy
premium, they help in significantly enhancing the scope of the plan.
Even if you are purchasing a basic health insurance policy, such add-
ons can make your health insurance more beneficial.

For instance, a lot of health insurance plans exclude several critical

illnesses such as cancer or heart diseases or do not cover treatments
arising from an accident. You can go ahead and purchase a critical
illness or accident cover add-on to make sure that your policy covers
such exclusions as well.

6. Tax Benefit

A large number of people in India end up purchasing health insurance

just because of the tax benefit it offers. While the tax benefit
shouldn't be the reason why you invest in health insurance, it still is a
significant advantage. Under Section 80D of the IT Act, an individual
below 60 years can claim a tax deduction of up to Rs. 25,000 for the
premiums paid against a health insurance policy. If you are above 60
years, the deduction limit is up to Rs. 50,000.

If you have also purchased health insurance for your below 60 years
parent/s, there is an additional tax deduction of Rs. 25,000. In case if
the age of your parent/s is above 60 years, the deduction available is
up to Rs. 50,000. So, if you are below 60 years and have purchased a
health policy for yourself, as well as, for your above 60 years parent/s,
the total tax deduction you can claim in a financial year is up to Rs.
75,000.
 DISADVANTAGES OF
HEALTH INSURANCE
1. Premium Increases with Age

Talking about the cons, one of the most important of them is the link
between health insurance premiums and age. Your age plays a crucial
role in deciding the premium of your policy. There can be a significant
difference in the premium amount when you purchase a health policy
when you are 30 years old and when you buy one after crossing 50
years.

In fact, it can also be challenging to find a health insurance policy once

you cross 60 years. As the chances of you suffering from a health
condition increase considerably with age, the insurers make up for the
increased risk by charging a higher premium. This is the reason why it
is said that you should prefer purchasing health insurance when you
are still young.

2. Waiting Period for Existing Health Problems

Most of the health insurance plans also have a waiting period of up to

2-3 years for pre-existing diseases. If you are already suffering from a
health condition such as blood pressure, diabetes, thyroid, etc. at the
time of purchasing a policy, any medical costs arising from these
conditions will not be covered until the waiting period is over.

This is one of the biggest disadvantages of health insurance policies as

it requires you to bear the healthcare expenses even when you have
purchased health insurance. This is another reason why you should
purchase a health insurance policy when you are young and healthy.
However, there are now insurance plans that come with a lower
waiting period.
3. Co-Pay Clause

In order to prevent false claim filing, many of the

insurance policies also have a co-pay or deductible clause.
If the policy you have purchased has a co-pay clause, you
will be required to share your medical expenses with your
insurance provider. The co-pay is generally defined in
percentage of the total healthcare bill.

For instance, if your policy has a co-pay clause of 20%,

you will be required to pay 20% of your hospital bill, and
your insurer will pay the rest. Such clauses are now
generally found in cheap health plans that attract people
with their low premiums. Before purchasing a policy, you
should always thoroughly check the policy document to
check the inclusions, exclusions, and other clauses.
 Data
analysis

Table 1 shows that health insurance premium increased from

Rs.1910 crores in 2006–2007 to Rs. 33011 crores in 2018–2019. But
claims incurred together with commission and management
expenses have grown from Rs. 3349 crores to Rs. 40076 crores
during the same period. So the claims and management expenses
Table 1.
Data showing health insurance premium earned and claims and
management expenses paid
incurred together is more than the health insurance premium

earned in all the years of our study thereby leading to underwriting

loss.

Total claims
and
Commission commission
Health and and
insurance manageme manageme
premium Claims nt exps nt exps
earned (Rs. incurred incurred incurred
Year Crs.) (Rs. Crs.) (Rs. Crs.) (Rs.Crs.)
2006–2007 1909.59 2687.49 662 3349
2007–2008 3224.27 3422.43 1139 4561
2008–2009 5017.47 5256.19 1849 7105
2009–2010 6351.82 6857.31 2362 9219
2010–2011 8783.61 8546.18 3350 11896
2011–2012 9660.52 9013.42 3239 12252
2018–2019 33010.89 30027.26 10049 40076
2012–2013 11413.76 10834.29 3630 14464

2013–2014 14373.7 14007.22 4167 18174

2014–2015 17260.69 17405.79 5343 22749

2015–2016 20456.57 20900.18 6629 27529

2016–2017 24709.75 26088.59 7059 33148

2017–2018 27875.24 26247.22 8329 34576

2018–2019 33010.89 30027.26 10049 40076

shows that health insurance premium increased from Rs.1910
crores in 2006–2007 to Rs. 33011 crores in 2018–2019. But claims
incurred together with commission and management expenses
have grown from Rs. 3349 crores to Rs. 40076 crores during the
same period. So the claims and management expenses incurred
together is more than the health insurance premium earned in all
the years of our study thereby leading to underwriting loss.

Claim incurred shown above is the outcome of the risk covered

against which premium is received and commission and
management expenses are incurred to obtain contract of
insurance. Both these expenses are important for insurance
companies to generate new business as stiff competition exists in
this sector since it was opened up in the year 2000.
FIGURE
 FIGURE.1
DISCRIPTION

Figure depicts the relationship between health insurance

premium earned and claims and management expenses
incurred by the insurance companies of the health insurance
sector for the period 2006–2007 to 2018–2019.

Bar chart between premiums earned and claims and

management expenses incurred show that claims and
management expenses together is higher than premium
earned in all the years of the study thereby leading to losses.
Claims, commission and management expenses are
important factors leading to the sale of insurance policies
thereby earning revenue for the insurance companies in the
form of premium. But proper management of claims and
commission and management expenses will help this sector
to improve its performance.
Table 2.provides insight into the performance of health
insurance sector in India. The growth of health insurance in
India has been from Rs.1909 crores for the financial year
2006–2007 to Rs. 33011crores for the financial year 2018–
2019. The growth percentage is 1629% i.e. growing at an
average rate of 135% per annum. Compounded Annual
Growth Rate (CAGR) is working out to be 27%.

From the same table, it can be inferred that health insurance

sector is making underwriting loss in all the financial years.
There is no specific trend can be seen, it has increased in
some years and decreased in some other years. Here
underwriting loss is calculated by deducting claims and
commission and management expenses incurred from health
insurance premium earned during these periods.

With every unit of increase in premium income the claims

incurred together with commission and management
expenses paid increased more than a unit. Thereby up setting
the bottom line. So instead of earning profit due to better
business through higher premium income, it has incurred
losses.

Underwriting principles needs to be streamlined so that

proper scrutiny of each policy is carried out so that
performance of this sector improves.
 Table 2.
Data on performance of health insurance sector in India

Net earned Commission

premium of and
health Claims management Underwriting
insurance (Rs. incurred (Rs. exps incurred profit/loss (Rs.
Year Crs.) Crs.) (Rs. Crs.) Crs.)
2006–2007 1909.59 2687.49 662 −1440

2007–2008 3224.27 3422.43 1139 −1337

2008–2009 5017.47 5256.19 1849 −2088

2009–2010 6351.82 6857.31 2362 −2867

2010–2011 8783.61 8546.18 3350 −3113

2011–2012 9660.52 9013.42 3239 −2592

2012–2013 11413.76 10834.29 3630 −3051

2013–2014 14373.7 14007.22 4167 −3801

2014–2015 17260.69 17405.79 5343 −5488

2015–2016 20456.57 20900.18 6629 −7073

2016–2017 24709.75 26088.59 7059 −8438

2017–2018 27875.24 26247.22 8329 −6701

2018–2019 33010.89 3
 FIGURE 2.
DESCRIPTION

It is seen from that there is stiff rise in premium

earned over the years but claims and commission
and management expenses incurred have also
grown equally and together surpassed earned
premium. So the net impact resulted in loss to this
sector which can also be seen in the figure. It is
also seen that loss is increasing over the years. So,
increase in earnings of revenue in the form of
premium is leading to increase in losses in this
sector which is normally not seen in any other
sectors.

But a time will come when commission and

management expenses will stabilize through
market forces to minimize underwriting losses. On
the other hand, it will also require proper
management of claims so that health insurance
sector can come of this unprofitable period.
 BENEFITS OF
FAMILY HEALTH
INSURANCE
 TYPES OF HEALTH
INSURANCE

1 FAMILY FLOATER HEALTH INSURANCE –

ALL THE FAMILY MEMBERS (YOU,YOUR
SPOUSE, CHILDERNS AND PARENTS) IN A SINGAL
POLICY.

2 CRITICLAL ILLNESS HEALTH PLAN –

PROVIDES FINANCIAL COVERAGE
TO THE INSURED IN CASE HE/SHE IS DIAGNOSED WITH
A LISTED CRITICAL ILLNESS/
DISEASE

3 TOP – UP HEALTH PLAN –

PROVIDE EXTRA COVERAGE IF YOUR EXISITING
HEALTH PLAN IS NOT ENOUGH TO MEET THE MEDICAL
BILLS
COMPANY AND BENEFITES
CARE HEALTH

•19000+ CashlessHealthcare Providers

•Coverage againstCOVID-19
•95.2% ClaimSettlement Ratio*
•Tax BenefitsUnder Section 80D
•30 Lacs+Claims Settled^
Care Health Insurance Limited is part of the Religare Group
and a direct subsidiary of Religare Enterprises Limited.
Kedaara Capital is a co-promoter of the company. Care Health
Insurance is an Indian health insurance company established in
July 2012.

PRODUCTS OF CARE HEALTH

•CARE SUPREME
•Health Insurance With Unlimited Coverage Up To Sum Insured
•CARE ADVANTAGE
•Health Insurance Plan With 1 Crore Cover
•CARE CLASSIC
•A Zone-Based Health Insurance For Families Across India
•CARE PLUS - YOUTH HEALTH INSURANCE PLAN
•Highly Flexible And Cost-Effective Health Plan
•CARE PLUS - THE COMPLETE HEALTH INSURANCE
PLAN
•Health Insurance With No Upper Age Limit
•CARE FOR 45+
•A Comprehensive Health Insurance Plan That Supports You In
Your Late 40s
•CARE FREEDOM
•Health Insurance Without Pre-Policy Check-Up
•CARE SENIOR
•Senior Citizen Health Insurance Plan Above 61
Years
•CARE HEART
•Health Insurance Plan Covering Pre-Existing
Heart Ailments
•SENIOR HEALTH ADVANTAGE
•Highly Affordable Plan With Comprehensive
Benefits
•CARE
•Health Insurance Plan For Family & Individual
•ENHANCE
•Super Top Up Health Insurance Plan
•JOY
•Maternity Insurance Plan With Baby Cover
 NIVA BUPA

•Hospitalisation cover against COVID-19

•Discount on premium up to 7.5% when you buy online
•30-minute cashless claim processing
•Pan-India cashless network of 7600+ hospitals
•Max Bupa is now Niva Bupa Health Insurance

•Niva Bupa Health Insurance Company Limited is an

Indian health insurance company, founded in 2008. It is
headquartered in New Delhi, India. It started as a joint
venture between Max India Limited and Bupa, the UK-
based international healthcare group
Niva Bupa Health Insurance (formerly known as Max Bupa
Health Insurance) is one of the most trusted standalone
health insurance partners. We have curated affordable and
comprehensive healthcare policies catering to the different
needs of our consumers.

We aim to give every Indian the confidence to access best

healthcare by providing health insurance plans as per your
needs. Our innovative and comprehensive health policies
have made us one of the leading health insurance and
medical insurance company in India.

PRODCUT OF NIVA BUPA

*Reassure
Our feature packed, best selling comperehensive health
insurance plan
*Senior First
A health insurance plan made for senior citizens
*Health Recharge
A Top-up plan for your loved ones protection
*Money Saver
Combination of base and top-up pian to offer protection for
your family’s health
*Health Premia
Our top selling plan for high networth individuals
 MANIPALCIGNA HEALTH INSURANCE

It’s not just Health Insurance, it’s HealthCare insurance!

It covers expenses beyond hospitalization. Doctor

consultations, laboratory test and pharmacy make up for
significant portion of our healthcare expenses. The Wellness
feature fetches you rewards based on the number of steps
taken per day towards better health maintenance i.e. premium
savings based on the steps you have walked per day.

Covers non-medical expenses

No surprise bills in your hospitalization ensuring 100% of claim.
ProHealth Prime takes care of your non-medical expenses.
Syringes, hand gloves, even registration charges and so many
other things which are neither medicines, nor consultancy, nor
diagnostics and yet the expenses which form significant part of
hospitalization charges.
Switch it off when you don’t need it

For the first time ever, you can switch off your cover when you
won’t be needing it, like while abroad, for a month & get a
discount on the next premium.

Choice of Any Room category

ProHealth Prime gives you complete peace of mind by

allowing you to opt for “Any room” category, suite or above, as
you deem fit.

Unlimited Restoration, for Real !!!

Your ProHealth Prime coverage restores to 100% of Sum

Insured unlimited times if at any point, you are short of
coverage. And that’s for both related and unrelated illnesses /
injuries. Applicable from 2nd claim onwards.

Annual Health Check up

From 1st year onwards for all the adults insured to take the
utmost care of your health, not just in illness but in wellness
too.
And yes, Pre Existing Diseases ARE Covered

There is only a 90-day waiting period for claiming the

expenses in case of hospitalization for illnesses such as
asthma, diabetes, hypertension, dyslipidemia, & obesity
related conditions. Other PED’s as per mentioned in Annexure.

1 Year Premium Waiver

When you go through the saddest moments and need the

financial support, we ensure insurance premium is not the
burden, to you and your family. If diagnosed with any of the
listed Critical Illnesses or in an unfortunate event of Accidental
Death, we waive off one year renewal policy premium so you
and your family stay protected throughout.
 SBI GENREAL

• Coverage Against Covid’19

• Cashless Treatments*
• Choose Customize Riders
• Tax Benefit u/s 80D
• IRDA Approved Plans

•1) PREAMBLE - This Policy is a contract of insurance issued by SBI

General (hereinafter called the ‘Company’) to the proposer mentioned in
the schedule (hereinafter called the ‘Insured’) to cover the person(s) named
in the schedule (hereinafter called the "Insured Persons). The policy is
based on the statements and declaration provided in the proposal Form by
the proposer and is subject to receipt of the requisite premium.

• 2) OPERATIVECLAUSE -If during the policy period one or more

Insured Person (s) is required to be hospitalized for treatment of an
illness or Injury at a Hospital/ Day Care Centre, following Medical
Advice of a duly qualified Medical Practitioner, the Company shall
indemnify Medically necessary, expenses towards the Coverage
mentioned in the policy schedule. Provided further that
, any amount payable under the policy shall be subject to the terms
of coverage (including any co-pay, sub limits), exclusions,
conditions and definitions contained herein. Maximum liability of
the Company under all such Claims during each Policy Year shall be
the Sum Insured (Individual or Floater) opted and Cumulative
Bonus (if any) specified in the Schedule.

3) DEFINITIONS

The terms defined below and at other junctures in the Policy have the
meanings ascribed to them wherever they appear in this Policy and, where,
the context so requires, references to the singular include references to the
plural; references to the male includes the female and references to any
statutory enactment includes subsequent changes to the same.

3.1. Accident means a sudden, unforeseen and involuntary event caused by

external, visible and violent means.
3.2. Age means age of the Insured person on last birthday as on date of
commencement of the Policy.
3.3. Any One illness means continuous period of illness and it includes
relapse within forty-five days from the date or last consultation with the
hospital where treatment has been taken.
3.4. AYUSH Treatment refers to hospitalisation treatments given under
Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.
3.5. An AYUSH Hospital is a healthcare facility wherein
medical/surgical/para-surgical treatment procedures and interventions are
carried out by AYUSH Medical Practitioner(s) comprising of any
a) Central or State Government AYUSH Hospital or
b) Teaching hospital attached to AYUSH College recognized by the Central
Government/Central Council of Indian Medicine/Central Council for
Homeopathy; Or
c) AYUSH Hospital, standalone or co-located with in-patient healthcare
facility of any recognized system of medicine, registered with the local
authorities, wherever applicable, and is under the supervision of a
qualified registered AYUSH Medical Practitioner and must comply with all
the following criterion:
d) Having at least 5 in-patient beds;
e) Having qualified AYUSH Medical Practitioner in charge round the clocks; iii.
Having dedicated AYUSH therapy sections as required and/or has equipped
operation theatre where surgical procedures are to be carried out,
f) Maintaining daily records of the patients and making them accessible to
the insurance company's authorized representative.
g) AYUSH Day Care Centre means and includes Community Health Centre
(CHC), Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any
such health centre which is registered with the local authorities, wherever
applicable and having facilities for carrying out treatment procedures and
medical or surgical/para-surgical interventions or both under the
supervision of registered AYUSH Medical Practitioner (s) on day care basis
without in-patient services and must comply with all the following
criterion: i.
h) Having qualified registered AYUSH Medical Practitioner(s) in charge; ii.
i) Having dedicated AYUSH therapy sections as required and/or has equipped
operation theatre where surgical procedures are to be carried out; iii.
j) Maintaining daily records of the patients and making them accessible to
the insurance company’s authorized representative.
k) Break in Policy means the period of gap that occurs at the end of the
existing policy term, when the premium due for renewal on a given policy
is not paid on or before the premium renewal date or within 30 days
thereof
 L) Cashless Facility means a facility extended by the insurer to the
insured where the payments, of the costs of treatment undergone by
the insured person in accordance with the Policy terms and conditions.
are directly made to the network provider by the insurer to the extent
Pre-authorisation is approved.
M) Condition Precedent means a Policy term or condition upon which
the Company's liability under the Policy is conditional upon.
N) Congenital Anomaly refers to a condition(s) which is present since
birth, and which is abnormal with reference to form, structure or
position.
a) Internal Congenital Anomaly Congenital anomaly which is not in the
visible and accessible parts of the body.
b) External Congenital Anomaly Congenital anomaly which is in the
visible and accessible parts of the body.
c) Co-payment means a cost sharing requirement under a health
insurance policy that provides that the policyholder/insured will bear a
specified percentage of the admissible claims amount. A copayment
does not reduce the Sum Insured.
O) . Cumulative Bonus means any increase or addition in the Sum
Insured granted by the insurer without an associated increase in
premium.
P) Day Care Centre means any institution established for day care
treatment of disease injuries or medical setup within a hospital and
which has been registered with the local authorities wherever
applicable, and is under the supervision of a registered and qualified
medical practitioner AND must comply with all minimum criteria as
under:
i. has qualified nursing staff under its employment;
ii. has qualified medical practitioner (S) in charge;
iii. has a fully equipped operation theatre of its own where surgical
procedures are carried out
iv. maintains daily records of patients and shall make these
accessible to the Company’s authorized personnel.
Q) Day Care Treatment means medical treatment, and/or surgical
procedure which is:
i. undertaken under general or local anaesthesia in a hospital/day
care centre in less than twentyfour hours because of
technological advancement, and ii. which would have otherwise
required a hospitalisation of more than twenty-four hours.
Treatment normally taken on an out-patient basis is not
included in the scope of this definition.
ii. Dental treatment means a treatment carried out by a dental
practitioner including examinations, filings (Where appropriate),
crowns, extractions and surgery.
iii. Disclosure to information norm: The policy shall be void and all
premium paid thereon shall be forfeited to the Company in the
event of misrepresentation, mis-description or non-disclosure of
any material fact.
iv. Emergeney Care: Emergency care means management for an
illness or injury which results in symptoms which occur suddenly
and unexpectedly, and requires immediate care by a medical
practitioner to prevent death or serious long term impairment
of the insured person’s health.
v. Family means, the Family that consists of the proposer and any
one or more of the family members as mentioned below i.
legally wedded spouse