F amily H ealth O ptima Insurance Plan (Revised). Features. Age at Entry : 5 months to 65 years Family size : 2A + 3C ( Maximum) Dependant children less than 25 years of age Renewability : Up to 65 years Coverage on
Family Health Optima
Age at Entry: 5 months to 65 years
Family size : 2A + 3C ( Maximum)
Dependant children less than 25 years of age
Renewability : Up to 65 years
Floater Basis : Single Sum Insured on Floater Basis covering all members of the family
For entry age between 61 and 65 years, only 2 Adults option is available for Sum Insured of Rs.3,00,000/- and above
20% Co pay on each and every eligible claim amount for insured persons between 61- 65 years, at entry level
Two Tier rating of Premium according to Zone
Zone 1 - Mumbai including Thane, Delhi ( Delhi city, Noida, Gurgoan, Ghaziabad & Faridabad) and the entire State of Gujarat
Zone 2 - Rest of India
Premium would be charged according to the residential address of the customer.
When a policy is charged as per Zone 2 rate and a treatment is taken in one of the Zone 1 cities, the difference in the premium is recovered from the claim amount
Hospitalization expenses incurred owing to disease, illness, sickness or accidents as inpatient in a registered hospital for a minimum period of 24 hours is covered on Cashless or reimbursement basis.
Reasonable Expenses incurred upto 30 days prior to the date of admission.
7% of the Hospitalization expenses (excluding room rent) subject to a maximum of Rs.5000/-
Room Rent : Class A Cities
2% of Sum Insured subject to maximum of Rs.5000 per day
Class B Cities
1% of Sum Insured subject to maximum of Rs.3000 per day
1% of Sum Insured subject to maximum of Rs.1000 per day
Day Care Procedures - 101 treatments covered as day care.
Limit for Cataract is based on the Sum Insured
SI Option Limit for Cataract
Automatic Restoration of SI
Where the sum insured is fully exhausted during the policy period, either under a single claim or multiple claims put together there is an automatic top up of Sum insured for the rest of the policy period
Automatic Restoration of SI – An Illustration
Mr.A has a Rs.5,00,000 policy and a claim is made in full for treatment of an ailment by him.
Rs.500,000 is again reinstated in the policy for the rest of the policy period.
No extra Premium is charged. This is automatic restoration.
This amount can now be availed by all members covered in the policy including Mr. A.
However in the case of Mr. A, the restored Sum Insured will be available for diseases other than for which the claim was made.
The policy holder is now bestowed with additional Sum Insured in case of a claim free year.
Different % age of bonus additions for Different Sum Insured options.
A maximum of 35% of Basic Sum Insured is accumulated as Bonus.
Ex: A policy with Sum insured of Rs.10,00,000/- will now automatically provide cover upto Rs. 12,50,000/- in the second year (I Renewal),Rs.13,50,000/- in the third year without any extra premium
What happens to Bonus Additions when there is claim in the subsequent year ?
The Bonus will be reduced by 50% following a claim under the policy.
The Bonus becomes Zero when there is a claim in the successive year also
Bonus additions would continue according to slab for the further claim free year
Persons who are suffering from or have suffered
from the following ailments cannot be issued policy –
Heart Problem (CVD)
First year ExclusionsBenign prostate hypertrophy, Hernia Hydrocele Fissures, Fistula in Anus / Piles Sinusitis Congenital internal disease/defect Treatment for Gall stone and
Treatment for Renal stone
First 2 year’s ExclusionsCataract
Hysterectomy following menorrhagia or fibromyoma, Treatment for Knee, Treatment for Joint Prolapse of intervertibral disc Varicose veins/ulcers
This policy is portable
Proposals from less than 45 years of age without any previous claim or PED, can be ported to this policy by the operating office.
The requisition has to be received 7 days before the date of expiry.
Beyond 45 years of age, portability acceptance routed through portability cell and applications will have to be received atleast 30 days prior to the date of Expiry.
Continuity benefits of First 30 days, First year exclusions, First two years’ exclusions and PED allowed according to the previous policy.
Cumulative Bonus of the previous insurer is not
given credit. However the Insured can opt for Sum Insured including the cumulative Bonus and Premium will be charged on the total Sum Insured.
Pre Insurance medical examination as per latest underwriting guidelines.
Tests to be taken as per the guidelines given.
Acceptance based upon the medical officer’s opinion of the MER.
Persons with adverse medical history may also be referred for medical examination.
Deductions under Sec 80 D of Income Tax Act is available for all modes of payment other than cash
Please refer the latest underwriting guidelines.
The No Claim Discount for a claim free year is withdrawn in view of introduction of Bonus.
The policy will now attract Bonus Additions as per the conditions.
Rs.4,00,000 claim free FHO policy is now renewed for Rs.5,00,000 Sum insured.
There will be a bonus addition of Rs.1,00,000. (25% of Basic Sum insured which is Rs.4,00,000)
Total Sum insured is Rs.6,00,000
(Rs.5,00,000 + Rs.1,00,000)
Premium is charged for Rs.5,00,000 Sum insured