Health Insurance Plan is a combination of Health Insurance and Investment with an objective of Income and Growth with Low risk, which provides for:

  • Domiciliary Treatment Benefit (DTB)
  • Hospital Cash Benefit (HCB)
  • Major Surgical Benefit (MSB)

This plan fulfills the need for the hospitalization expenses in case of insured falling sick/undergoing Major Surgical (see list). apart form investment.

DTB (treatment taken at home) is also paid sub. to certain conditions if min. 3 years’ premium have been paid.

Extent of claim benefit of HCB  & MSB can be decided while taking the policy itself. LIC will release the funds to the Policyholder as & when claim for HCB & MSB is submitted.

A portion of the premium will be utilized for Health Insurance Cover. Each premium paid by the PI will be invested (after deduction of Allocation Charges) to purchase units.

Premium Allocation Charge: For the 1st year will be 30%  & 6% thereafter.

Health Insurance Charges:

HCB & MSB charge will be taken every month by canceling appropriate no. of units out of  Policy Fund. However, for an insured Child, charges for MSB shall be deducted from the policy anniversary coinciding with or immediately following the 18th birthday of that child. These charges, will be based on age nbd and hence may increase every year.

In case of HCB, the charges during the policy term will be applied on the Initial Daily Benefit.

Other Charges:

  • Policy Administration Charge: 1st policy year 75/- Subsequent year 25/-
  • Service Tax: on Health Insurance charges (Currently@ 12.36%)

Above Charges will be deducted by canceling appropriate no. of units out of Policy Fund per month.

  • Fund Management Charge (FMC): 1.25% p.a. of Unit Fund deductible on daily basis, the NAV thus declared will be of FMC

Hospital Cash Benefit (HCB):

Benefit payable on Hospitalizaiton: If any of the insured lives is hospitalized due to Accidental Body Injury or Sickness and the stay in hospital exceeds a continuous period of 48 hours, then for any continuous period of 24 hours or part thereof thereafter, provided such part stay exceeds a continuous period of 4 hours in a Non-ICU ward/room, an amount equal to the Applicable Daily Benefit, and if admitted in ICU, double the Benefit shall be payable  subject to terms & conditions.

The amount of  Initial Daily Benefit will increase at each policy anniversary by 5% till it reaches a max. of 1.5 times which is considered as Applicable Daily Benefit.

Hospital Cash Benefit Limits:

  • In the 1st Policy year a max. of 18 days hospitalization of which not more than 9 days shall be in ICU for each insured. From 2nd year onwards it will be 60 & 30 days respectively.
  • No benefit would be paid  for the first 48 hours (2days ) of hospitalization.
  • HCB would be payable, in respect of each Insured, during entire term of Policy shall be limited to a max. of 365 days & in case of Insured Child it will be 90 days till the completion of 5 years of child’s age
    Applicable for both HCB/MSB:
  • if a person is covered under various policies under this plan, then the max. benefit under all policies put, then the max. benefit under all policies put together shall not exceed the cap on benefits under this plan.
  • MSB will be payable only if occurred within India if  Hospitalization under HCB & Surgery under.

Major Surgical Benefit (MSB):

MSB S.A. percentage, as specified shall be payable, in the event of any Insured lives, undergoing any of the listed surgeries. This benefit will remain fixed throughout. The above benefit will remain fixed throughout. The above benefit is sub. to exclusions & following terms & conditions:

  • In case of claim, eligible for payment and regardless of actual costs, LIC will pay chosen MSB amount, calculated as a percentage of  S.A.  against each of the eligible surgeries.
  • MSB for any Surgery is not payable, more than once for same Surgery during policy term
  • Max. Benefit Amount payable in any Policy year during the Cover Period shall not exceed 100% of S.A. in respect of each insured.
  • MSB shall be paid as a lump sum and is subject to proof to the satisfaction of LIC.
  • Total Benefit Amount payable in respect of each Insured during the Cover Period shall not exceed a lifetime max lifetime max. limit of  3 times the S.A. Once the total Benefit amount Paid in respect of an Insured equals this lifetime max. limit, the MSB in respect of that Insured will cease.
  • All surgical procedures claimed should be confirmed as essential & required, by a qualified Physical/Surgeon & to the satisfaction of LIC.
  • Child included in the policy will be automatically covered for MSB from policy anniversary on which age l.b.d. is 18 yrs.

There will be no option for the PI to exclude the cover. Till that period such child is not covered for this benefit.

Domiciliary Treatment Benefit (DTB):

If at least 3 years’ premium have been paid, an amount  shall be payable out of Policy Fund equal to the actual amount spent to meet any medical expenses/domiciliary treatment over and above those paid through HCB & MSB incurred in respect of any of the Insured lives at any time, sub. to following conditions:

  1. Max. 50%  of the policy Fund (Leaving at least one annualised prem. after payment.)
  2. In a policy year Max. 2 payments allowed .
  3. At least Rs. 2,500 is  Claimed amount ;

DTB ceases in respect of the child reaching 25 years n.b.d.

Expenses being claimed should not be older than one year. Payments subject to production of proof of medical treatment & supporting bills for treatment.

On completion of Policy term benefits:If any Balance in Policy Fund, will be payable.

On Death Payable Benefit:

  1. If on single life policy is issued: In case of death of the legal heir, PI or the nominee shall get the Fund Value of units held in the Policy Fund.
  2. If one or more insured lives (other than PI) are also covered:

On death of  PI before completion of 3 years form the D.O. C of policy- the nominee or legal heir shall get the Fund Value of units held in the Policy Fund and Policy will terminate.

From D.O.C. of policy-payment of Premiums will cease on death of  PI after completion of 3 years.  However, cover shall continue for or till the fund is sufficient to recover the charges for HCB & MSB, surviving insured lives till max. benefit ceasing age  which is earlier.

Till the fund is sufficient to recover all the charges or till the end of policy term, which is earlier Policy will continue. At the end of the policy term, balance in the Policy Fund, if any shall be refunded is earlier. At the end of the policy term, balance amount, if any, will be refunded to nominee/legal heir.

One the death of the Insured member(s), other than PI — payment of premiums cover for PI and other Insured members, if any shall continue.

Benefits will have to be claimed by the legal guardian if all the children covered are minor. On death of PI and spouse (whether insured or not), shall continue and can be claimed by the eldest major child covered.

On death of all Insured members- The nominee or legal heir shall get the Fund Value of units held in the Policy Fund.

Surrender benefits: Surrender value, if any, only after completion of 3rd policy anniversary is payable. It will be the Policy Fund value at the date of the date of surrender. No Surrender charge.

ADDITIONAL FEATURES:

  • INCREASE IN PREMIUM :increase in premium: in multipls of Rs. 500 shall be allowed. There will not be any increase in benefitsn amount under HCB & MSB.
    REDUCTION IN PREMIUM PAID:  May be allowed sub. to min premium & benefit limits. How ever, there would be no change in benefit amounts provided to PI & other insured lives.
    Cover to new addition members: If the PI gets married/remarried during policy term, spouse can be included

No benefits are available and no payment will be made by LIC for any claim for HCB & MSB on account of any of the following:

  1. 1. Pre-existing condition- any medical condition or related condition that have arisen at some point prior to the commencement of this coverage known to PI or insured will be deemed to be pre-existing.

The following conditions will be also deemed to be “pre-existing”;

  • A condition arising between signing the application form & conformation of acceptance by LIC.
  • A sickness, illness, complication or ailment arising out of or connected to the pre-existing illness.

In case of MSB, Surgery triggered by health related causes (not by Accident) within first 180 days from the Date of Commencement & 90 Days from the Date of revival/reinstatement after discontinuance of cover.

  • In case of HCB : treatment not performed by a Physician or treatment of a purely experimental nature.
  • In case of MSB: any treatment not performed by a Physician / Surgeon.
  • Any treatement including Surgery that is performed un-conventionally under experimental conditions & purely experimental in future.
  • Sickness classified as an Epidemic by Govt.
  • Circumcision, cosmetic or aesthetic treatment, change of gender surgery or treatment, treatment (unless due to illness/accidental Bodily Injury with in 6 months)
  • Hospitalisation/Surgery for donation of an organ.
  • Hospitalisation / Surgery for correction of birth detects or congenital anomalies.
  • Dental treatment or surgery of any unless necessitated by Accidental Bodily Injury.
  • Convalescence, general debility, nervous or other breakdown, rest cure, congenital diseases or defect or anomaly, sterilisation or infertility (diagnosis and treatment ), any sanatorium, spa or rest cures or long term care or hospitalistion undertaken as a preventive or recuperative measure.
  • Self afflicted injuries or conditions(attempted suicide), and/or the use or misuse of any drug or alcohol.
    • Any sexually transmitted diseases like AIDS.
    • Removal or conditional or replacement of any material that was implanted in a former Surgery before Date of Cover commencement.
    • In case of MSB any diagnosis or treatement or Surgery arising form or traceable to pregnancy (whether uterine or extra uterine).

In case of HCB any dignosis or treatement arising form  or traceable to pregnancy(whether uterine or extra uterine ), children including caesarean

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