A STUDY TOWARDS HEALTH CARE PLUS POLICY OF ICICI BANK

A Project submitted to University of Mumbai for partial completion of the

degree of bachelor in Commerce (Banking and Insurance)

Under the Faculty of Commerce

By

Muskan jain

Under the Guidance of

Dr. Aashish Jani

Smt . Mithibai Motiram Kundnani of Commerce and Economics .

32 Road, T.P.S III , Bandra, Mumbai 400050

APRIL – 2020

SMT . MITHIBAI COLLEGE

OF COMMERCE AND ECONOMICS

SMT. MITHIBAI MOTIRAM KUNDNANI COLLEGE OF COMMERCE AND ECONOMICS

Adv , Nari Gursahani Rd , T.P.S III, Mumbai, Maharashtra - 400050

Cetificate

This is to certify that Ms . Muskan Jain has worked and duly completed her Project work for the degree
of Bachelor in Commerce (Banking and Insurance) under the Faculty of Commerce in the subject of
Research Methodology and her project is entitled, The Study Towards Health care plus Policy of Icici
Bank under my supervision.

I further certify that the entire work has been done by the learner under my guidance and that no part
of it has been submitted previously for any Degree or Diploma of any University.

It is her own work and fact reported by her personal findings and investigation

Name and signature of

Guiding Teacher
Declaration by learner

I the undersigned Ms. Muskan Jain here by , declare that the work embodied in his project work titled
The study towards the heath care plus policy of ICICI bank form my own contribution to the research
work carried out under guidance of Dr. Aashish jani is a resultof my own research work and has been not
previously submitted to any other University for any other Degree/ Diploma to this or any other
University .

Wherever reference has been made to previous works of others, it has been clearly indicated as such
and included in the bibliography.

I, here by further declare that all information of this document has been obtained and presented in
CHAPTER 1 : INTRODUCTION

Insurance is a means of protection from financial loss . It is a form of risk management , primary
used to hedge against the risk of a contingent or uncertain loss An entity which provides
insurance is known as insurer , insurance company , insurance carrier or underwriter. A person or
entity who buys insurance is known as insured or policy holder Health insurance coverage is not
bigger and better than ever with new ICICI health care plus policy . This new policy is designed
to take care of all additional payments which are likely to arise when over and above the amount
of your existing health insurance cover . Individual between 5 – 65 years are eligible for this
policy. Proposer needs to be aged 18 years or above under health care plus policy . Individuals
proposed whose age is 56 years and above have to undergo medical test at ICICI lombard
designated diagnostic centres . Health care plus policy is a lifetime renewal policy . Premium
payable on the renewal and on subsequent continuation of cover are subject to change with prior
approval of IRDA. The policy may be renewed by mutual consent and in such event the renewal
premium shall be paid to the company or before the date of expiry of the policy and in no case
later than 30 days (grace period) from the expiry of the policy .This policy allows to include or
exclude a member in the plan only at the time of renewal . Protect your family from all
uncertainties with ICICI Lombard health care Plus insurance policy. It is a plan that takes care of
the excess payment that may arise when hospitalization bill and other expenses exceed the
existing cover Moreover when you don’t have any cover, you can still opt for this plan and get
covered for the sum insured . Maximum 4 members can be covered in this plan . In health care
plus policy premium is eligible for deduction under section 80 D of Income tax act . Any
individual between 5 – 65 years of age can avail the policy and free health check up facility for
any one insured member on policy renewal .

Health care plus policy coverage covers :

 Hospitalization expenses
 Hospital room rent/ Bed charges
 Medicine and surgical expenses
 Diagnostic test
 Doctor surgeon fees

. Pre existing ailments are covered after 4 years of continuous coverage with the insurance .
Policy holder enjoys benefits such as flexible sum insured , no co payment , pre existing diseases
can be covered after four continuous year of coverage of company , long term coverage of one to
two years , you individual covers each member of the family , flexible deductibles , free health
check at the time of policy renewal , income tax benefit under section 80 D . Healthcare plus
policy contains two components – sum insured and deductible . Sum insured is the part that
defines maximum amount that can be claimed under this policy. Deductible is the amount after
which any claim becomes admissible under this policy .
 1.1 Reasons for getting a health care plus policy :

Income tax benefit : Premiums are also eligible for tax deduction under 80 D of Indian
Income tax Act. Individuals upto 65 yearss of age can claim a deduction up to 25000 for
premium paid by themselves.

Rising medical cost : The medical cost have dramatically risen lately .So in case of a medical
emergency, consumers end up sending their savings, which takes a toll on their future
plans.Reports highlights that Indians primarily depend on their own savings when it comes to
tackling health problems.

Covers expenses ; Health care plus policy coverage covers hospitalization expenses , hospital
room rent ,medicine and surgical expense, doctors fees, bed fees , diagnostic test .

Safeguard finance : The health care plus insurance policy helps in meeting unexpected health
expense so savings are not disturbed .

Cashless hospitalization facility : The company /tpa may provide a health card to that insured
under this policy to avail of cashless hospitalization facility. The insured can avail of cashless
hospitalization facility under this policy at the time of admission intoany hospital which has a tie
up with the TPA/Company by production of this health card subject to terms and conditions for
the usage of the health card as communicated to the insured by Tpa company.

Cashless hospitalization facility will not be available if treat under this policy to avail of cashless
hospitalization facility. The insured can avail of cashless hospitalization facility under this policy
at the time of admission intoany hospital which has a tie up with the TPA/Company
1.2 Features of health care plus policy :

 Individual cover for the each member of the family .

Example : Mr Badhwar, his wife and their son were covered under a health insurance policy with
sum insured of 2 lakhs . He opts for health care plus policy for his son.This policy has sum
insured of 5 lakhs with deductible of 2 lakhs. In case of hospitalization where the bill of his son
amounted to 6 lakhs. The health policy covers 2 lakhs while the rest of the amount got claimed
under health care plus policy.

 Single premiums among different age groups.

 Health care plus policy is available in one year or two years option.
 Individuals between the age of 5 years to 65 years can avail the policy .
 Cover is independent of any other health insurance plan availed by insurer .
 Flexible sum insured and deductibles.

PLAN SUM INSURED DEDUCTIBLES

PLAN 1 5 Lakhs 2 Lakhs

PLAN 2 8 Lakhs 3 Lakhs

PLAN 3 10 Lakhs 4 Lakhs

1.3 Significance of health care plus policy :

 It is difficult for a family to quickly arrange for huge amounts of money required for
treatment .
 Most of the savings of a family are in form of fixed assets, which cannot be liquidated.
 Can avoid the burden of paying huge amount in the medical emergencies by just paying
small annual premium.
 A good health insurance policy would usually covers expenses towards medical fees ,
doctor,s consultation fees , hospitalization expenses , bed charges , free health checkup.

1.4 Limitations of health care plus policy :

Cost : Health care insurance policy can be very costly . Cost may be so high that people may
end up struggling to make payments. This can be quite challenging for those who have a low
incomes or are self – employed. Health care coverage for families may cause an added
financial burden .

Pre Existing Exclusion : People who have pre – existing illness have to undergo a waiting
period which is typically four years to be covered . This becomes major obstacle for older
individuals with pre – existing medical conditions . It does not include illness received for the
recent past but also includes illness for which there were signs or symptoms in the 48 months
prior to pay first premium .

1.5 Payment options

Cashless : The person does not need to pay the hospital as the insurer directly pays to the
hospital . The policyholder and all those who are mentioned in the policy can undertake the
treatment from those hospital approved by the insurer .

Reimbursement : After staying the duration of the treatment , the patient can take the
reimbursement from the insurer for the treatment that is covered under the policy undertaken.


ment is taken in a hospital where the TPA/Company does not have tie up to provide such facility.
1.6 Key Benefits of health care plus policy :

 Individual cover for each member of the family.

 No sublimits on room rent, hospitalization expenses, medical and surgical expenses,
diagnostic test, doctors fees.
 No Co payment.
 Policy becomes effective when the claim amount in single incidence/hospitalization is
beyond deductible.
 Policy holder enjoys the benefit of flexible sum insured.
 Long term coverage of 1 year and 2 years.
 Free health checkup for any one insured member in the plan upon policy renewal.
 Income tax benefit under section 80 D.
 Flexible Deductibles.
 Health care plus policy helps in meeting the unexpected health care plus expenses so that
savings are not disturbed.
 Entry age of members proposed for this insiurance is 5-65 years.
 Supplementary plan for an existing health cover.
 Coverage of pre – existing diseases after 4 th consecutive renewal.
 Lifetime renewability.
 Reimbursement of hospitalization expenses.
 Can be availed when coverage of existing plan is adequate .
 Cashless facility is available at 4500 network hosoitals across India.
1.7 TERMS OF RENEWABILITY :

 Lifetime renewability
 The policy can be renewed under the prevailing health care plus policy plan or its nearest
substitute approved by IRDA in the event , that the plan has been discontinued
 The maximum entry age under this policy is 65 years.
 The policy may be renewed by mutual consent and in such event the renewal premium
shall be paid to the company on or before the Date of expiry of the policy and in no case
later than 30 days (grace period) from the expiry of the policy However, the company
shall not be liable to any claim for the period for which premium is not received by the
company .
 Sum insured can be enhanced only upon renewal, subject to underwriter,s approval.
 This policy allows to include or exclude a member in the plan only at the time of
renewal .
1.8 TERMS AND CONDITIONS APPLICABLE TO THE POLICY :

It is a condition precedent to the Company's liability that upon the discovery or happening of any Illness
or Bodily Injury that may give rise to a Claim under this Policy, the Insured or (if the Insured is
incapacitated or a minor, then his representative) shall undertake the following :

The Insured or his representative, as the case may be, shall give immediate notice to the appointed TPA
or the Company (in case no TPA is appointed) by calling the toll free number as specified in the health
card/ Policy provided to the Insured and also in writing at the address of the Company with particulars
as below:

i. Policy Number

ii. Name of the Insured availing treatment

iii. Policyholder's relation to the Insured

iv Nature of Illness or Bodily Injury

v. Name and address of the attending Medical Practitioner and the Hospital

vi. Any other information that may be relevant to the Illness/ Bodily Injury/ Hospitalisation. The above
information needs to be provided to the TPA/Company immediately and prior to availing treatment and
in any case within 7 days from date of admission/date of availing treatment and in any case within 7

PRIOR AUTHORIZATION :

For cashless Hospitalization, the Insured must contact the TPA /Company at least 48 hours before a
planned Hospitalization. In an emergency situation the TPA should be contacted within 24 hours of
Hospitalization.

CLAIM PROCESSING :

The TPA appointed by the Company will process the Claim on behalf of the Company and make all
payments. The Policyholder or the Insured shall deliver, at their own costs, to the TPA/Company, within
90 days of the Insured's discharge from Hospital, any and all information and documentation in original
concerning the Claim or the Company's liability for it, including but not limited to:

i. Duly completed claim form signed by You & Medical Practitioner. The claims form can be
downloaded from our website www.icicilombard.com
ii. Original bills, receipts and discharge certificate/card from the Hospital/Medical Practitioner.
iii. Original bills from chemists supported by proper prescription.
iv. Original investigation test reports and payment receipts.
v. Indoor case papers
vi. PRIOR AUTHORIZATION :

For cashless Hospitalization, the Insured must contact the TPA /Company at least 48 hours before a
planned Hospitalization. In an emergency situation the TPA should be contacted within 24 hours of
Hospitalization.

CLAIM PROCESSING :

The TPA appointed by the Company will process the Claim on behalf of the Company and make all
payments. The Policyholder or the Insured shall deliver, at their own costs, to the TPA/Company, within
90 days of the Insured's discharge from Hospital, any and all information and documentation in original
concerning the Claim or the Company's liability for it, including but not limited to:

i. Duly completed claim form signed by You & Medical Practitioner. The claims form can be
downloaded from our website www.icicilombard.com
ii. Original bills, receipts and discharge certificate/card from the Hospital/Medical Practitioner.
iii. Original bills from chemists supported by proper prescription.
iv. Original investigation test reports and payment receipts.
v. Indoor case papers

vi . Medical Practitioner's referral letter advising Hospitalization in non-Accident cases

vi. Any other document as required by the Company or Company's TPA to investigate the Claim or
Our obligation to make payment for it. If so requested by the TPA/Company, the Insured will
have to submit to a medical examination by the Company's or TPA's nominated Medical
Practitioner as and when the TPA/Company considers reasonable and necessary. The cost of
such examination shall be borne by the Company. In the event of Insured's death, written notice
accompanied by a copy of the post mortem report (if any) should be given to the Company
within 14 days regardless of whether any prior notice has been given to the company .

PAYMENT OF CLAIMS :
 The Deductible amount shall be applicable to each and every Claim separately .

 No indemnity under this Policy is available if the period of Hospitalization is less than 24 hours
except in the case of Specified Treatment .

SETTLEMENT OF CLAIM
The Settlement of claims would be done by Us within 30 days after receipt of last necessary
documents, any rejections if done, would be provided with proper reasons by Us. The role of the
TPA (if any) would be limited to facilitate the flow of information between Insured and the
Company. Penal interest provision shall be as per Regulation 9(6) of (Protection of Policyholders'
Interests) Regulations, 2002.
1 ."Accident" is a sudden, unforeseen and involuntary event caused by external and visible and violent
means.

2. "Alternative treatments" are forms of treatments other than treatment Allopathy" or "modem
medicine" and includes Ayurveda, Unani, Sidha and Homeopathy in the Indian conte

3. "Break in policy" 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.

4. "Cashless facility" means a facility extended by the insurer to the insured where the payments, of the
costs of treatment undergone by the insured in accordance with the policy terms and conditions, are
directly made to the network provider by the insurer to the extent preauthorization approved.

5. "Chronic condition" is defined as a disease, illness, or injury that has one or more of the following
characteristics:-it needs ongoing or longterm monitoring through consultations, examinations, check-
ups, and / or tests-it needs ongoing or long-term control or relief of symptoms- it requires your
rehabilitation or for you to be specially trained to cope with it-it continues indefinitely-it comes back or
is likely to come back.

6. "Claim" means a demand by the Insured per episode of Hospitalisation, defined by the date of
admission and discharge, for payment of Medical Charges as covered under the Policy.

7 . "Co-payment" is a cost-sharing requirement under a health insurance policy that provides that the
policyholder/insured will bear a specified percentage of the admissible claim amount. A co-payment
does not reduce the Sum Insured. "Condition Precedent" shall mean a policy term or condition upon
which the Insurer's liability under the policy is conditional upon.

8 . "Renewal" defines the terms on which the contract of insurance can be renewed on mutual consent
with a provision of grace period for treating the renewal continuous for the purpose of all waiting
periods.
9 .‘’Domiciliary Hospitalisation" means medical treatment for an illness/disease/injury which in the
normal course would require care and treatment at a hospital but is actually taken while confined at
home under any of the following circumstances:

i. The condition of the patient is such that he/she is not in a condition to be moved to a hospital,
or
ii. ii. The patient takes treatment at home on account of non availability of room in a hospital.
"Dental treatment" is treatment carried out by a dental practitioner including examinations,
fillings (where appropriate), crowns, extractions and surgery excluding any form of cosmetic
surgery/implants.

10. "Deductible" is a cost-sharing requirement under a health insurance policy that provides that the
insurer will not be liable for a specified rupee amount in case of indemnity policies and for a specified
number of days/hours in case of hospital cash policies which will apply before any benefits are payable
by the insurer. A deductible does not reduce the Sum Insured.

11 . Emergency Care is management for a severe illness or injury which results in symptoms which occur
suddenly and unexpectedly, requires immediate care by a medical practitioner to prevent death or
serious long term impairment to the insured person's health

12 . Grace Period means the specified period of time immediately following the premium due date
during which a payment can be made to renew or continue a policy in force without loss of continuity
benefits such as waiting periods and coverage of Pre Existing Diseases. Coverage is not available for the
period for which no premium is received.

13 . "Hospital" means any institution established for in-patient care and day care treatment of illness
and/or injuries and which has been registered as a hospital with the local authorities under the Clinical
Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the
Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:

 Has qualified nursing staff under its employment round the clock;
 Has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-
patient beds in all other places;
 Has qualified medical practitioner(s) in charge round the clock;
 Has a fully equipped operation theatre of its own where surgical procedures are carried out;
 Maintains daily records of patients and makes these accessible to the insurance company's
authorized personnel.

14. Room Rent" means the amount charged by a hospital for the occupancy of a bed on per day (24
hours) basis and shall include associated medical expenses.
1.9 Scope of the cover of health care plus policy :

The Company will indemnify the Insured, subject always to the Limit of Indemnity and the Deductible
amount, for the Medical Charges incurred by such Insured as an in-patient in a Hospital where the
Hospitalization is for a minimum period of 24 consecutive hours, as a result of suffering Illness or Bodily
Injury during the Period of Insurance, which on the written advice of a Medical Practitioner requires
Hospitalization. Notwithstanding anything contained herein, this Benefit shall not apply to any Medical
Charges incurred by the Insured in any place or geographical area other than in India, unless otherwise
agreed by the Company in writing by way of any Endorsement.

The following charges shall be reimbursable under the policy:

 Room rent, boarding and nursing expenses as charged by the Hospital where the Insured availed
medical treatment.
Intensive Care Unit (ICU) charges.
 Surgeon, anaesthetist, Medical Practitioner, consultants, specialist fees.
 Anaesthesia, blood, oxygen, operation theatre charges, surgical consumables, medicines and
drugs, diagnostic materials and X-ray, dialysis, chemotherapy, radiotherapy, cost of pacemaker,
cost of artificial limbs.
 1.10 Eligibility for Health care plus insurance policy by ICICI :
 The policy is renewable till the aged above 70 years.
 Maximum two adults can be covered under a single policy .
 The proposer needs to be aged above 18 years.
 The entrollment age of member can be between 5 to 65 years of age .
 Income Tax benefit u/s section 80 D of the income tax Act , 1961 can only be availed for
self, spouse,parents, and dependent children .

Documents required while buying health care plus policy :

Age proof : Proof such as birth certificate , passport, voter ID.

Identity proof : Proves that should be one,s citizenship like driving license , passport , voter ID , Pan
card , Aadhar card .

Address proof : Proof that should be clearly mentioned the address such as electricity bill , ration card ,
driving license ,passport and telephone bill .

Some plans require medical check up .

Passport size photo.

CHAPTER 2 : Research Methodology

2.1 Objectives :-

To study the concept of health care plus policy .

To analysis the benefits of health care plus policy.

To know about payment options.

To study the history of health care plus policy.

To explain about the cost and duration of health care plus policy .

2.2 Hypothesis

HO : There is no significance difference towards health care plus policy of ICICI bank.

H1 : There is significant difference towards health care plus policy of ICICI bank.
RESEARCH DESIGN / SAMPLE DESIGN :

A. Research Method :

B.Universe/ Population : The current study is conducted in Mumbai district of Maharashtra state .

C. Samle Area : The sample is collected from the sample Areas of Mumbai which include Bandra and
Khar .

D. Sample Size : The sample selected from the uuniverse includes 30 respondants .

E. Sample Techniques : The sample technique used for the research project is questionnaire and
survey method .

F. Sample Period : The sample period for the research is between January – February.
2.4 DATA COLLECTION :

A. Primary Data (Survey – Questionnaire)

Name:

Gender: