FAQs for Optima Enhance

• A maximum of 6 members can be covered in an Individual Optima Enhance policy, a maximum of 4 adults and a maximum of 5 children can be included in a single policy. The 4 adults can be a combination of Self, Spouse, Father or Mother, Father In-law or Mother In-law. E.g. 2 Adult + 4Children or 1 Adult + 5 Children). Either set of parents/parents-in law can be covered
• In a family floater policy a maximum of 5 members can be covered under a single policy with a maximum of 2 Adults. The 2 adults can be a combination of Self, Spouse, Father or Mother, Father In-law, Mother In-law.

• Individual – Maximum 5 child dependents
• Family Floater – Maximum 3 child dependents

• Minimum entry age-91days
• Maximum entry age-70years
• Dependent children between 91 days to 5 years can be covered if either parent is covered under the same policy.
• There is no maximum cover ceasing age on renewals

25 years

“Deductible” means a cost-sharing requirement under a health insurance policy where the insurance company will not be liable for eligible medical expenses up to a specified rupee amount, as opted i.e. it is the amount upto which the insurance company will not pay for all the claims incurred in a policy year under the policy. A Deductible does not reduce Sum Insured.

Optima Enhance is an aggregate deductible plan, here deductible will be calculated as a sum of all claims in a Policy year. Example of Deductible: Mr. X has policy (Policy Period - 1st Jan 2017 to 31st Dec 2018) with Sum Insured of Rs. 500,000 and with a deductible of Rs. 500,000.

Scenario 1: For multiple claims in a year In May 2017, he is hospitalized and a claim is filed for Rs. 400,000. Claim is not admissible in this scenario since his deductible is Rs. 500,000. In June 2017, he is hospitalized and a claim is filed for Rs. 200,000. As the total claims under the policy for the year is Rs. 6,00,000 (4,00,000 +2,00,000), he is eligible to claim for Rs. 1,00,000 (i.e. Rs. 6,00,000 - Rs. 5,00,000).

Scenario 2: For a single claim In May 2017, he is hospitalized and a claim for Rs. 6,00,000 is filed, in this scenario claim payment will be made for Rs. 100,000 [Rs. 6,00,000-Rs. 5,00,000]

As per product terms and conditions we would offer to opt for any indemnity health insurance Policy (without any Deductible) offered by Us for same Sum Insured without re-evaluation of health status or any pre policy check.

Any decrease in deductible will be subject to acceptance by Medical Underwriting bases Health Declaration Form.

This option is only available at 10th renewal, 15th renewal or between the age group of 55-60 years provided you have spent at-least 10 years in the policy. This option cannot be availed after the age of 60 years.

No, deductible for all dependents must be the same

No

No, the Restore Sum Insured will always be 100% of the basic sum insured irrespective of the deductible amount selected

Such documentation will include but is not limited to the following:

• Our claim form, duly completed and signed for on behalf of the Insured Person.
• Original bills with detailed breakup of charges (including but not limited to pharmacy purchase bill, consultation bill, and diagnostic bill) and any attachments thereto like receipts or prescriptions in support of any amount claimed which will then become Our property.
• Original payment receipts
• All reports, including but not limited to all medical reports, case histories, investigation reports, treatment papers, discharge summaries.
• Discharge Summary containing details of ,Date of admission and discharge, detailed clinical history, past history, procedure details and details of treatment taken
• Invoice/Sticker of the Implants.
• A precise diagnosis of the treatment for which a claim is made.
• A detailed list of the individual medical services and treatments provided and a unit price for each.
• Prescriptions that name the Insured Person and in the case of drugs: the drugs prescribed, their price and a receipt for payment. Prescriptions must be submitted with the corresponding Medical Practitioner’s invoice.
• Obstrition history/ Antenatal card
• Treating doctors certificate regarding the duration & etiology

Note: When original bills, receipts, prescriptions, reports and other documents are submitted to the other insurer or to the reimbursement provider, verified photocopies attested by such other organisation/provider have to be submitted.