LITERATURESALES
PROSPECTUS
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11
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SWASTHYA PRATHAMMICRO INSURANCE PRODUCT
Disclaimer: This is only a summary of the product features and is for reference purpose only. The details of benefits
available shall be as described in the policy document, and will be subject to the policy terms, conditions and
exclusions. Please call our customer service if you require any further information or clarification.
Statutory Warning: Prohibition of rebates (under section 41 of Insurance Act 1938); no person shall allow or offer
to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance
in respect of any kind of risk relating to life or property, in India, any rebate of the whole or part of the commission
payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or
continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published
prospectus or the tables of the insurer. Any person making default in complying with the provision of this section
shall be punished with fine, which may extend to five hundred rupees.
What to do next
Phone: 1800 3010 3333 (Toll Free) or 011-3300 3333
Web: www.maxbupa.com
If you wish to know more about Max Bupa’s Swasthya Pratham Micro
Insurance Product and/or would like a personal quote, speak to our specially
trained sales team or your local advisor. They’ll take time to fully understand
your requirements and help you to select the right plan for you.
&LITERATURE&LITERATURESALES&SALES
Max Bupa Health Insurance Company LimitedCorporate Office : 2nd Floor, Salcon Ras Vilas, D-1, District Centre, Saket, New Delhi 110017
Registered Office : Max House, 1 Dr. Jha Marg, Okhla, New Delhi 110020www.maxbupa.com
‘Max’, Max Logo are registered trademarks of Max India Limited“Bupa” and the HEARTBEAT logo are the registered service marks of the The British United Provident Association Limited
All these marks are being used under license by Max Bupa Health Insurance Company Limited.
Insurance is the subject matter of solicitation
Max India Limited: A Reputation for Excellence
Introducing Max Bupa Health Insurance Company Limited, a joint venture between Max India Limited and Bupa
Finance Plc., U.K. We believe in nurturing long-term relationship with our customers by providing the highest levels of
quality in service.
OUR PARENT COMPANIES
Max Group brings expertise in insurance and
healthcare with a strong presence in Life Insurance
(through Max New York Life Insurance Company
Limited), Healthcare (through Max Healthcare Institute
Ltd.) and Clinical Research (through Max Neeman
Medical International Limited).
A Rs.7,700 crore group, it has over 700 offices across
more than 500 locations in India as well as 4 million
customers, and over 1 lac people, all focused on
delivering customer satisfaction (Source-Max India Ltd.
Annual Report 2009-10).
Bupa: 60 Years of Care
Established in 1947 as the British United Provident
Association, Bupa today has over 10 million customers
in over 190 countries (Source-www.maxbupa.com).
Bupa Group brings in a wealth of experience in serving
customers directly in health insurance across the
world. In addition to quality health insurance, Bupa
runs care homes for elderly people and the young
disabled, health assessments & health coaching and
workplace health programmes for customers.
Recognition and Awards
SWASTHYA PRATHAM MICRO INSURANCE PRODUCT
Start a healthy relationshipSWASTHYA PRATHAM MICRO INSURANCE PRODUCTYour search for high quality health insurance stops here.
Swasthya Pratham Micro Insurance Product is a group
health insurance cover which is simple to buy and easy
to understand. In addition to providing a core health
insurance cover to suit your needs, this plan helps you
proactively take care of the health of your group and
their dependants. We are here to build a long term
healthy relationship with your group and its members.
We believe that a healthy relationship is built by
understanding your needs, by coming closer to you,
through a continuous dialogue with you on what
matters the most to you.
Policy Design
• Swasthya Pratham Micro Insurance Product can
cover the members of your group and her/his
family under the same limit. The cover includes the
member, members spouse and any three
dependent children (under 18 years). Family under
the Swasthya Pratham Micro Insurance Product
includes the following:
1. Spouse (Legally married)
2. Son
3. Daughter
• This policy covers Main member in the age 18-65
Years and dependents in the age group 3 months
to 65 years.
• The tenure of the policy is one year.
Sum Insured
• The sum insured options- range from Rs. 5,000 to
Rs. 30,000 for Individuals and Rs 10,000 to Rs
30,000 for family floater policies, depending on
the plan you choose. The details of the plans are
available in the product benefits table.
Product Features and Benefits–Key HighlightsThe policy covers reasonable and customary expenses
incurred towards medical treatment taken during the
Policy Period for an Illness or an Accident. We cover the
following expenses:
1. In-patient Treatment: Medical Expenses for:
(i) Doctors’ fees
(ii) Diagnostics Tests
(iii) Medicines, drugs and consumables
(iv) Intravenous fluids, blood transfusion, injection
administration charges
(v) Operation theatre charges
(vi) The cost of prosthetics and other devices or
equipment if implanted internally during a
Surgical Operation.
(vii) Intensive Care Unit charges
(viii) Room (General Ward), boarding expenses
(ix) Nursing expenses
2. Hospital Accommodation: Reasonable and
Customary charges for Hospital accommodation.
3. Pre & Post hospitalization Medical Expenses: Medical Expenses incurred due to Illness up to 7
days period immediately before an Insured
Person’s admission to a Hospital and 15 days
immediately after an Insured Person’s discharge
from a Hospital. These expenses are restricted to Rs
150 per hospitalization or 1.5% of Sum Insured
(whichever is higher).
4. Day Care Procedures: Medical Expenses for day
care procedures where such procedures are
undertaken by an Insured Person as an inpatient in
Max India Limited:
• Max New York Life was declared a “Superbrand” by
Superbrands India in the 3rd edition of Consumer
Superbrands 2008’
• CII-Exim Bank Award for Business Excellence awarded to Max New York Life in 2008
• CIO 100 Award for technology implementation
Bupa:
• The Health Insurance Company of the Year Award -
awarded at the U.K. Health Insurance Awards 2009
• Best International Private Medical Insurance provider
2008 - awarded at the U.K. Health Insurance Awards
• Best Medical Insurer Company (2008, Bupa Arabia)
- awarded at the Jeddah Chamber of Commerce and
Industry Health Committee Awards
• Best Healthcare Provider of the Year - awarded at the
U.K. Corporate Adviser Awards 2009
• Best Individual Private Medical Insurance Provider
- awarded at the U.K. Money Marketing Awards 2009 Sourse: www.bupa.com
2
Max India Limited: A Reputation for Excellence
Introducing Max Bupa Health Insurance Company Limited, a joint venture between Max India Limited and Bupa
Finance Plc., U.K. We believe in nurturing long-term relationship with our customers by providing the highest levels of
quality in service.
OUR PARENT COMPANIES
Max Group brings expertise in insurance and
healthcare with a strong presence in Life Insurance
(through Max New York Life Insurance Company
Limited), Healthcare (through Max Healthcare Institute
Ltd.) and Clinical Research (through Max Neeman
Medical International Limited).
A Rs.7,700 crore group, it has over 700 offices across
more than 500 locations in India as well as 4 million
customers, and over 1 lac people, all focused on
delivering customer satisfaction (Source-Max India Ltd.
Annual Report 2009-10).
Bupa: 60 Years of Care
Established in 1947 as the British United Provident
Association, Bupa today has over 10 million customers
in over 190 countries (Source-www.maxbupa.com).
Bupa Group brings in a wealth of experience in serving
customers directly in health insurance across the
world. In addition to quality health insurance, Bupa
runs care homes for elderly people and the young
disabled, health assessments & health coaching and
workplace health programmes for customers.
Recognition and Awards
SWASTHYA PRATHAM MICRO INSURANCE PRODUCT
Start a healthy relationshipSWASTHYA PRATHAM MICRO INSURANCE PRODUCTYour search for high quality health insurance stops here.
Swasthya Pratham Micro Insurance Product is a group
health insurance cover which is simple to buy and easy
to understand. In addition to providing a core health
insurance cover to suit your needs, this plan helps you
proactively take care of the health of your group and
their dependants. We are here to build a long term
healthy relationship with your group and its members.
We believe that a healthy relationship is built by
understanding your needs, by coming closer to you,
through a continuous dialogue with you on what
matters the most to you.
Policy Design
• Swasthya Pratham Micro Insurance Product can
cover the members of your group and her/his
family under the same limit. The cover includes the
member, members spouse and any three
dependent children (under 18 years). Family under
the Swasthya Pratham Micro Insurance Product
includes the following:
1. Spouse (Legally married)
2. Son
3. Daughter
• This policy covers Main member in the age 18-65
Years and dependents in the age group 3 months
to 65 years.
• The tenure of the policy is one year.
Sum Insured
• The sum insured options- range from Rs. 5,000 to
Rs. 30,000 for Individuals and Rs 10,000 to Rs
30,000 for family floater policies, depending on
the plan you choose. The details of the plans are
available in the product benefits table.
Product Features and Benefits–Key HighlightsThe policy covers reasonable and customary expenses
incurred towards medical treatment taken during the
Policy Period for an Illness or an Accident. We cover the
following expenses:
1. In-patient Treatment: Medical Expenses for:
(i) Doctors’ fees
(ii) Diagnostics Tests
(iii) Medicines, drugs and consumables
(iv) Intravenous fluids, blood transfusion, injection
administration charges
(v) Operation theatre charges
(vi) The cost of prosthetics and other devices or
equipment if implanted internally during a
Surgical Operation.
(vii) Intensive Care Unit charges
(viii) Room (General Ward), boarding expenses
(ix) Nursing expenses
2. Hospital Accommodation: Reasonable and
Customary charges for Hospital accommodation.
3. Pre & Post hospitalization Medical Expenses: Medical Expenses incurred due to Illness up to 7
days period immediately before an Insured
Person’s admission to a Hospital and 15 days
immediately after an Insured Person’s discharge
from a Hospital. These expenses are restricted to Rs
150 per hospitalization or 1.5% of Sum Insured
(whichever is higher).
4. Day Care Procedures: Medical Expenses for day
care procedures where such procedures are
undertaken by an Insured Person as an inpatient in
Max India Limited:
• Max New York Life was declared a “Superbrand” by
Superbrands India in the 3rd edition of Consumer
Superbrands 2008’
• CII-Exim Bank Award for Business Excellence awarded to Max New York Life in 2008
• CIO 100 Award for technology implementation
Bupa:
• The Health Insurance Company of the Year Award -
awarded at the U.K. Health Insurance Awards 2009
• Best International Private Medical Insurance provider
2008 - awarded at the U.K. Health Insurance Awards
• Best Medical Insurer Company (2008, Bupa Arabia)
- awarded at the Jeddah Chamber of Commerce and
Industry Health Committee Awards
• Best Healthcare Provider of the Year - awarded at the
U.K. Corporate Adviser Awards 2009
• Best Individual Private Medical Insurance Provider
- awarded at the U.K. Money Marketing Awards 2009 Sourse: www.bupa.com
2
a Hospital for a continuous period of less than 24
hours. Any procedure undertaken at the
out-patient department of a Hospital will not be
covered.
List of Day Care Procedures covered under the
Policy is as follows:i. Haemo-Dialysisii. Parenateral Chemotherapyiii. Radiotherapyiv. Eye Surgeryv. Lithotripsy ( kidney stone removal)vi. Tonsillectomyvii. D&Cviii. Surgery of Hydroceleix. Surgery of Prostrate
x. Gastrointestinal Surgery xi. Genital Surgery xii. Surgery of Nose xii. Surgery of Throat xiv. Surgery of Ear xv. Surgery of Urinary System xvi. Treatment of fractures / dislocation (excluding
hair line fracture), Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalization.
xvii. Laparoscopic therapeutic surgeries that can
be done in a day care
Additional Benefits that can be purchased for extra premium
a) Maternity & New Born Benefits:
i) Maternity Benefits: This benefit is available
for the Primary Insured or his spouse provided
that the Primary Insured and his/her spouse,
are both covered under the same Policy.
However in the case of a widow covered
under the Policy, the benefit under this clause
can be availed in respect of the pregnancy
conceived by her when she and her husband
were both covered under the immediately
preceding policy with Us, We will also cover
medically necessary termination of pregnancy.
However, we do not cover expenses in respect
of harvesting and storage of stem cells.
a. We will pay Rs. 3000 for Normal Delivery and
Rs. 5000 for Cesarean
b. No home birth allowed
c. Cover 2 deliveries, in the entire policy lifetime
per couple
d. Pre and post hospitalization covered with
maximum 7 days of pre and 15 days of post
hospitalization. This will be part of Maternity
Cover
e. Expense related to Pre Mature Delivery will be
part of overall Maternity Cover
ii) New Born Baby: The new born baby will be
covered as an insured person from day 91
with no extra premium till renewal.
b) Personal Accident: If the Primary Insured or his
spouse (provided that she is an Insured Person)
dies during the Policy Period solely and directly due
to an Accident which occurs during the Policy
Period, then We will pay the Personal Accident Sum
Insured specified in the Schedule. We will not
make any payment under this endorsement if the
death of the Primary Insured or his spouse is due
to or arises from any of the following:
a. Any existing disability
b. Self injury
c. Natural calamities
d. Homicide
e. Suicide
f. Influence of liquor or drugs
g. Result of racing, big games, hunting,
mountaineering and adventure sports
h. Insanity
i. Any war or act of terrorism
j. Result of being part of nuclear group
Cover is available only to Primary Insured and his/her
Spouse. Cover is available for age 18 years to 65
years.
Out Patient Benefits
We will cover expenses upto Rs. 500 (per cover under
each Certificate of Insurance) related to following
diagnostic tests, if prescribed by a Doctor and are
conducted only in the Network Hospitals:
a. ECG;
b. Chest X-ray;
c. Test for Hemoglobin;
d. Test for Blood Sugar;
e. Test for Urea;
f. Test for Creatinine
Claims made in respect of this benefit will not be
subject to the Sum Insured.
Meal Allowance
We will pay meal allowance per day if the Insured
Person is admitted in a Network Hospital for each
continuous and completed period of 24 hours of the
Hospitalization, after first 48 hours of Hospitalization,
provided that We have accepted an In-patient
Hospitalization claim . We will pay Rs 30 per day
maximum up to Rs 210 per cover under each
Certificate of Insurance.
Claims made in respect of this benefit will not be
subject to the Sum Insured.
Wage Loss
We will pay for the loss of wage per day if the Primary
Insured is admitted in a Network Hospital for each
continuous and completed period of 24 hours of the
Hospitalization, after first 48 hours of Hospitalization
provided that We have accepted an In-patient
Hospitalization . We will pay Rs 100 per day of
hospitalization maximum of Rs 700 per cover under
each Certificate of Insurance.
Claims made in respect of this benefit will not be
subject to the Sum Insured.
Transport Allowance (In case of Inpatient Treatment
for emergency cases only): Max upto Rs 1000 per
cover under each Certificate of Insurance and Max
Rs 600 per hospitilsation. Claims made in respect of
this benefit will not be subject to the Sum Insured.
By Stander Allowance (Subject to 48 hours
hospitilisation): Rs 50 per day max of Rs 350 (as
applicable under the policy) under each Certificate of
Insurance. By stander here means, means A person
who accompanies the insured during his/her
hospitalization throughout the entire tenure of
hospitalization.
Claims made in respect of this benefit will not be
subject to the Sum Insured.
Waivers available for Purchase:
• 30 day no claim/waiting period from policy
inception
• 24 month waiting period from for Specific
Exclusions
• Pre-existing disease exclusions waivers
Waiting Periods and Exclusions
Claims for the following are not covered:
• Pre-Existing Conditions: Benefits will not be
available for Pre-existing Conditions until 48
months of continuous coverage have elapsed since
the inception of the first Policy with us.
• 30 Days Waiting Period: We will not cover any
treatment taken during the first 30 days since the
commencement of the Policy, unless the treatment
needed is a result of an Accident or Emergency.
This waiting period does not apply for any
subsequent and continuous renewals of Your
Policy.
2 3
a Hospital for a continuous period of less than 24
hours. Any procedure undertaken at the
out-patient department of a Hospital will not be
covered.
List of Day Care Procedures covered under the
Policy is as follows:i. Haemo-Dialysisii. Parenateral Chemotherapyiii. Radiotherapyiv. Eye Surgeryv. Lithotripsy ( kidney stone removal)vi. Tonsillectomyvii. D&Cviii. Surgery of Hydroceleix. Surgery of Prostrate
x. Gastrointestinal Surgery xi. Genital Surgery xii. Surgery of Nose xii. Surgery of Throat xiv. Surgery of Ear xv. Surgery of Urinary System xvi. Treatment of fractures / dislocation (excluding
hair line fracture), Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalization.
xvii. Laparoscopic therapeutic surgeries that can
be done in a day care
Additional Benefits that can be purchased for extra premium
a) Maternity & New Born Benefits:
i) Maternity Benefits: This benefit is available
for the Primary Insured or his spouse provided
that the Primary Insured and his/her spouse,
are both covered under the same Policy.
However in the case of a widow covered
under the Policy, the benefit under this clause
can be availed in respect of the pregnancy
conceived by her when she and her husband
were both covered under the immediately
preceding policy with Us, We will also cover
medically necessary termination of pregnancy.
However, we do not cover expenses in respect
of harvesting and storage of stem cells.
a. We will pay Rs. 3000 for Normal Delivery and
Rs. 5000 for Cesarean
b. No home birth allowed
c. Cover 2 deliveries, in the entire policy lifetime
per couple
d. Pre and post hospitalization covered with
maximum 7 days of pre and 15 days of post
hospitalization. This will be part of Maternity
Cover
e. Expense related to Pre Mature Delivery will be
part of overall Maternity Cover
ii) New Born Baby: The new born baby will be
covered as an insured person from day 91
with no extra premium till renewal.
b) Personal Accident: If the Primary Insured or his
spouse (provided that she is an Insured Person)
dies during the Policy Period solely and directly due
to an Accident which occurs during the Policy
Period, then We will pay the Personal Accident Sum
Insured specified in the Schedule. We will not
make any payment under this endorsement if the
death of the Primary Insured or his spouse is due
to or arises from any of the following:
a. Any existing disability
b. Self injury
c. Natural calamities
d. Homicide
e. Suicide
f. Influence of liquor or drugs
g. Result of racing, big games, hunting,
mountaineering and adventure sports
h. Insanity
i. Any war or act of terrorism
j. Result of being part of nuclear group
Cover is available only to Primary Insured and his/her
Spouse. Cover is available for age 18 years to 65
years.
Out Patient Benefits
We will cover expenses upto Rs. 500 (per cover under
each Certificate of Insurance) related to following
diagnostic tests, if prescribed by a Doctor and are
conducted only in the Network Hospitals:
a. ECG;
b. Chest X-ray;
c. Test for Hemoglobin;
d. Test for Blood Sugar;
e. Test for Urea;
f. Test for Creatinine
Claims made in respect of this benefit will not be
subject to the Sum Insured.
Meal Allowance
We will pay meal allowance per day if the Insured
Person is admitted in a Network Hospital for each
continuous and completed period of 24 hours of the
Hospitalization, after first 48 hours of Hospitalization,
provided that We have accepted an In-patient
Hospitalization claim . We will pay Rs 30 per day
maximum up to Rs 210 per cover under each
Certificate of Insurance.
Claims made in respect of this benefit will not be
subject to the Sum Insured.
Wage Loss
We will pay for the loss of wage per day if the Primary
Insured is admitted in a Network Hospital for each
continuous and completed period of 24 hours of the
Hospitalization, after first 48 hours of Hospitalization
provided that We have accepted an In-patient
Hospitalization . We will pay Rs 100 per day of
hospitalization maximum of Rs 700 per cover under
each Certificate of Insurance.
Claims made in respect of this benefit will not be
subject to the Sum Insured.
Transport Allowance (In case of Inpatient Treatment
for emergency cases only): Max upto Rs 1000 per
cover under each Certificate of Insurance and Max
Rs 600 per hospitilsation. Claims made in respect of
this benefit will not be subject to the Sum Insured.
By Stander Allowance (Subject to 48 hours
hospitilisation): Rs 50 per day max of Rs 350 (as
applicable under the policy) under each Certificate of
Insurance. By stander here means, means A person
who accompanies the insured during his/her
hospitalization throughout the entire tenure of
hospitalization.
Claims made in respect of this benefit will not be
subject to the Sum Insured.
Waivers available for Purchase:
• 30 day no claim/waiting period from policy
inception
• 24 month waiting period from for Specific
Exclusions
• Pre-existing disease exclusions waivers
Waiting Periods and Exclusions
Claims for the following are not covered:
• Pre-Existing Conditions: Benefits will not be
available for Pre-existing Conditions until 48
months of continuous coverage have elapsed since
the inception of the first Policy with us.
• 30 Days Waiting Period: We will not cover any
treatment taken during the first 30 days since the
commencement of the Policy, unless the treatment
needed is a result of an Accident or Emergency.
This waiting period does not apply for any
subsequent and continuous renewals of Your
Policy.
2 3
• Mastoidectomy (operation to remove piece of
bone behind the ear)
• Tympanoplasty (Surgery to repair tympanic
membrance aka eardrum)
• Undescended testis
• Surgery of genito urinary tract
• Permanent Exclusions: Addictive conditions and
disorders; Ageing and puberty; Artificial life
maintenance; Circumcision; Conflict and disaster;
Congenital conditions; Convalescence and
rehabilitation; Cosmetic surgery; Dental/oral
treatment; Domicillary Treatment; Drugs and
dressings for outpatient or take-home use;
Eyesight; Experimental treatment; Health hydros,
nature cure, wellness clinics etc.; HIV and AIDS;
Hereditary conditions; Items of personal comfort
and convenience; Non-allopathic treatment;
Neurological and Psychiatric Conditions; Obesity;
Organ Donor; Out Patient Treatment; Reproductive
medicine - Birth control & Assisted reproduction;
Self-inflicted injuries; Sexual problems and gender
issues; Sexually transmitted diseases; Sleep
disorders; Speech disorders; Treatment for
developmental problems; Treatment received
outside India; Unrecognised physician or facility;
Unlawful activity.
For details of permanent exclusions please read Terms
and Condition document or visit:
www.maxbupa.com/exclusions
Cancellation1. Cancellation/Termination :
a. Automatic Cancellation/Termination:
The Policy shall automatically terminate in the case
of death of all the Insured Persons.
b. Cancellation by Us:
We may terminate this Policy/ cover under
Certificate of Insurance by sending 30 days prior
written notice to Your address shown in the
Schedule without refund of premium if in Our
opinion:
i. You or any Insured Person or any person acting on
behalf of either has acted in a dishonest or
fraudulent manner, provided false or incorrect
information, or suppressed any important
information, under or in relation to this Policy/ cover
under Certificate of Insurance; and/or
ii. Continuance of the Policy/ cover under Certificate of
Insurance poses a moral hazard;
1. Cancellation by Policyholder:The Policyholder may terminate this Policy by giving 7 days’ prior written notice to Us. We shall cancel the Policy and refund the premium for the period as mentioned herein below, provided that no claim has been reported under the Policy by or on behalf of any claim, if reported after the termination date of the Policy.
Length of time Reffund of premiumPolicy in forceup to 30 days 75%up to 90 days 50%up to 180 days 25%exceeding 180days 0%
The Policyholder shall be responsible for making refund of premium to the Primary Insured in proportion to premium, if any, paid by them.
Renewal Information1. Renewal Premium: The renewal premium is
payable on or before the due date as shown in the
Schedule. The premium may change on renewal.
2. Waiting Period: The Waiting Periods mentioned in
the policy wording will get reduced by 1 year with
every continuous renewal of your Swasthya Pratham
Micro Insurance Product.
3. Maximum Age: There is no maximum cover ceasing
age in this policy.
Claims Procedure
• Cashless Hospitalization Facility for Network
Hospitals: We will provide cashless hospitalization
facility at our network hospitals. For any treatment
taken at non network hospital the insured will
have to bear 20% co-pay for the claim amount.
We/TPA will pre-authorise all cashless in-patient and
day care procedure, if intimated to us/TPA 72 hours
before hospitalization (within 48 hours after
hospitalization for emergency). Under cashless
Hospitalization, claims are paid directly to the
Network Hospital. For cashless Hospitalization TPA will
make the payment of the amounts assessed to be due
directly to the Network Hospital. The treatment must
take place within 15 days of the pre-authorization
date and pre-authorization is only valid if all the
details of the
authorized treatment, including dates, diagnosis,
treatment, clinical details, Hospital and locations,
match with the details of the actual treatment
received.
• All Other Claims for Reimbursement: We should be
notified in writing with a request to pre-authorise
expenditure to be reimbursed under this Policy at leat
72 hours prior to the planned date of such treatment,
consultation or procedure being taken and We must
have pre-authorised such treatment, consultation,
service or procedure. In an Emergency the Insured
Person should notify Us in writing within 48 hours of
Hospitalization.
• In case of all claims made for treatment at
Out-Of-Network hospittals, the insured will have to
bear 20% co-pay for te amont assessed for the
reimbursement in respect of claim.
• To claim re-imbursements for any Illness or Accident
or medical condition that requires Hospitalization, the
Insured Person should provide us/TPA the documents
listed below, within 15 days of the Insured Person's
discharge from Hospital:
• Specific Waiting Periods: For all Insured Persons,
the conditions listed below will be subject to a
waiting period of 24 months and will be covered in
the third Policy Year as long as the Insured Person
has been insured continuously under the Policy
without any break:
• Gout
• Rheumatism
• Hypertension
• DM
• Varicose veins & Varicose ulcers
• Hemorrhoids (Piles)
• Migraine / Vascular headaches
• Stones in the urinary system
• Stones in billiary system
• Surgery on tonsils / adenoids
• Any type of cysts, nodules, polyps
• Any type of breast lumps
• Treatment of spondylosis/spondylitis - any type
• IVDP & such other degenerative disorders
• Benign Hypertrophic Prostatectomy
• Hysterectomy / Myomectomy done due to Fibroids and/or Mennorhagia
• Heart diseases
• Any type of Carcinoma/sarcoma/blood cancer
• Osteo Arthritis of any joint
• Gastric and duodenal Ulcers
• Thyroidectomy for nodule/multinodular goitre
• Varicocele
• Spermatocele
• Rectal Prolapse
• D&C
• Vitrectomy & retinal detachment surgery for retinopathy
• Amputation due to diabetes
• Fistula in ano
• Fissure in ano
• Her nia
• Hydrocele
• Sinusitis
• Knee / hip joint replacement
• CRF or end stage renal failure
• Cataract
4 5
• Mastoidectomy (operation to remove piece of
bone behind the ear)
• Tympanoplasty (Surgery to repair tympanic
membrance aka eardrum)
• Undescended testis
• Surgery of genito urinary tract
• Permanent Exclusions: Addictive conditions and
disorders; Ageing and puberty; Artificial life
maintenance; Circumcision; Conflict and disaster;
Congenital conditions; Convalescence and
rehabilitation; Cosmetic surgery; Dental/oral
treatment; Domicillary Treatment; Drugs and
dressings for outpatient or take-home use;
Eyesight; Experimental treatment; Health hydros,
nature cure, wellness clinics etc.; HIV and AIDS;
Hereditary conditions; Items of personal comfort
and convenience; Non-allopathic treatment;
Neurological and Psychiatric Conditions; Obesity;
Organ Donor; Out Patient Treatment; Reproductive
medicine - Birth control & Assisted reproduction;
Self-inflicted injuries; Sexual problems and gender
issues; Sexually transmitted diseases; Sleep
disorders; Speech disorders; Treatment for
developmental problems; Treatment received
outside India; Unrecognised physician or facility;
Unlawful activity.
For details of permanent exclusions please read Terms
and Condition document or visit:
www.maxbupa.com/exclusions
Cancellation1. Cancellation/Termination :
a. Automatic Cancellation/Termination:
The Policy shall automatically terminate in the case
of death of all the Insured Persons.
b. Cancellation by Us:
We may terminate this Policy/ cover under
Certificate of Insurance by sending 30 days prior
written notice to Your address shown in the
Schedule without refund of premium if in Our
opinion:
i. You or any Insured Person or any person acting on
behalf of either has acted in a dishonest or
fraudulent manner, provided false or incorrect
information, or suppressed any important
information, under or in relation to this Policy/ cover
under Certificate of Insurance; and/or
ii. Continuance of the Policy/ cover under Certificate of
Insurance poses a moral hazard;
1. Cancellation by Policyholder:The Policyholder may terminate this Policy by giving 7 days’ prior written notice to Us. We shall cancel the Policy and refund the premium for the period as mentioned herein below, provided that no claim has been reported under the Policy by or on behalf of any claim, if reported after the termination date of the Policy.
Length of time Reffund of premiumPolicy in forceup to 30 days 75%up to 90 days 50%up to 180 days 25%exceeding 180days 0%
The Policyholder shall be responsible for making refund of premium to the Primary Insured in proportion to premium, if any, paid by them.
Renewal Information1. Renewal Premium: The renewal premium is
payable on or before the due date as shown in the
Schedule. The premium may change on renewal.
2. Waiting Period: The Waiting Periods mentioned in
the policy wording will get reduced by 1 year with
every continuous renewal of your Swasthya Pratham
Micro Insurance Product.
3. Maximum Age: There is no maximum cover ceasing
age in this policy.
Claims Procedure
• Cashless Hospitalization Facility for Network
Hospitals: We will provide cashless hospitalization
facility at our network hospitals. For any treatment
taken at non network hospital the insured will
have to bear 20% co-pay for the claim amount.
We/TPA will pre-authorise all cashless in-patient and
day care procedure, if intimated to us/TPA 72 hours
before hospitalization (within 48 hours after
hospitalization for emergency). Under cashless
Hospitalization, claims are paid directly to the
Network Hospital. For cashless Hospitalization TPA will
make the payment of the amounts assessed to be due
directly to the Network Hospital. The treatment must
take place within 15 days of the pre-authorization
date and pre-authorization is only valid if all the
details of the
authorized treatment, including dates, diagnosis,
treatment, clinical details, Hospital and locations,
match with the details of the actual treatment
received.
• All Other Claims for Reimbursement: We should be
notified in writing with a request to pre-authorise
expenditure to be reimbursed under this Policy at leat
72 hours prior to the planned date of such treatment,
consultation or procedure being taken and We must
have pre-authorised such treatment, consultation,
service or procedure. In an Emergency the Insured
Person should notify Us in writing within 48 hours of
Hospitalization.
• In case of all claims made for treatment at
Out-Of-Network hospittals, the insured will have to
bear 20% co-pay for te amont assessed for the
reimbursement in respect of claim.
• To claim re-imbursements for any Illness or Accident
or medical condition that requires Hospitalization, the
Insured Person should provide us/TPA the documents
listed below, within 15 days of the Insured Person's
discharge from Hospital:
• Specific Waiting Periods: For all Insured Persons,
the conditions listed below will be subject to a
waiting period of 24 months and will be covered in
the third Policy Year as long as the Insured Person
has been insured continuously under the Policy
without any break:
• Gout
• Rheumatism
• Hypertension
• DM
• Varicose veins & Varicose ulcers
• Hemorrhoids (Piles)
• Migraine / Vascular headaches
• Stones in the urinary system
• Stones in billiary system
• Surgery on tonsils / adenoids
• Any type of cysts, nodules, polyps
• Any type of breast lumps
• Treatment of spondylosis/spondylitis - any type
• IVDP & such other degenerative disorders
• Benign Hypertrophic Prostatectomy
• Hysterectomy / Myomectomy done due to Fibroids and/or Mennorhagia
• Heart diseases
• Any type of Carcinoma/sarcoma/blood cancer
• Osteo Arthritis of any joint
• Gastric and duodenal Ulcers
• Thyroidectomy for nodule/multinodular goitre
• Varicocele
• Spermatocele
• Rectal Prolapse
• D&C
• Vitrectomy & retinal detachment surgery for retinopathy
• Amputation due to diabetes
• Fistula in ano
• Fissure in ano
• Her nia
• Hydrocele
• Sinusitis
• Knee / hip joint replacement
• CRF or end stage renal failure
• Cataract
4 5
- Duly filled claim form(s) stamped by group (main
policy holder) supported by Investigation test
reports, Original bills, receipts and discharge
certificate/card from the Hospital/ Doctor/Chemists
Doctor's referral letter advising hospitalization in
non-accident cases, the post mortem report (in
case of insured person’s death), First Information
Report (FIR) for medico-legal cases
- Details of any other insurance policy that may
respond to the claim.
We/TPA might request for any other documents or
information that we believe may be required.
Disclosures on Continuity
If a Primary Insured ceases to be Your member/
borrower during the Policy Period, then cover under
the Policy for that Primary Insured and his Dependants
(who are named as Insured Persons in the Schedule)
will immediately and automatically cease unless the
Primary Insured gives Us a written request prior to or
within 5 days of the date of cessation of employment,
to issue a new health insurance policy to himself and
his Dependents (who were named as Insured Persons
in the Schedule) for cover up to his Sum Insured under
the Policy, on payment of premium in full for the new
policy. The Primary Insured understands and agrees
that:
(i) the issue of a new policy shall be subject to Our underwriting requirements, as applicable from time to time, and We may obtain additional information before issuing a new policy;
(ii) We are not bound to continue all terms and conditions of the present cover under the Policy of the Primary Insured and his Dependents under the new policy, however for calculation of waiting periods including for pre-existing conditions under the new policy the time spent by Primary Insured and his Dependants under this Policy may be taken into account, provided new policy is taken without any break from this Policy. Coverage under the new policy shall be available only for the period for
which the premium has been received by Us;
(iii) We are not bound to continue the cover for the
Primary Insured or all his Dependents.
Nomination Facility: Primary Insured can, at the
inception or at any time before the expiry of the Policy,
make a nomination for the purpose of payment of
claims.
How to Buy Max Bupa Swasthya Pratham Micro Insurance Product1. The Micro Insurance Product is sold through all the
direct and indirect channels such as, Agency,
Corporate Agency, DST and Micro Insurance
Agents.
2. Every Customer will be assigned a unique customer
identification number on the Max Bupa system.
3. A Max Bupa proposal form to be completed after
the Customer provides the required information as
stated below :
• Insured’s name, date of birth, designation and address, as necessary.
• As above for all dependants to be covered by the policy.
• Any existing health insurance policy details and claims history, if applicable.
• Selection of Swasthya Pratham Micro Insurance Product sum insured, waivers and
additional cover. • Disclosure of any pre-existing medical
conditions with details. • Medical history report for applicant and
dependants, if necessary. • Signature and date on application, wherever
applicable.
4. All proposals accepted by Max Bupa are internally
processed and enrolled into the Max Bupa system,
and premium payments are cleared.
5. Where proposals are not accepted due to
unacceptable risk then customer too receive
communications from Max Bupa advising of the
same and specific reasons for the cover denied.
Swasthya Pratham - Micro Insurance ProductProduct benefit table
6 7
Overall Sum Insured (SI) Rupees
5,000 10,000 20,000 30,000Base Line Cover Benefits (%%)
In-patient treatment (^^^^^^^^^^^^^ ^^^^^^^ ) Doctors’ fees
Diagnostics Tests
Medicines, drugs and consumables
Intravenous fluids, blood transfusion,
injection administration charges
Intensive Care Unit charges
Anaesthesia, Blood, Oxygen,Operation Theatre Covered up to SI Charges, Surgical appliances
Radiotherapy, Cost of Prosthetic Devices,
implants
Medicines and Drugs, Diagnostic Materials and
X-ray, Dialysis, Chemotherapy
Nursing Expenses
Hospital Accommodation General Ward (Boarding Expense)Pre and post hospitalization expenses includingdoctor's consultation, diagnostics tests, medicines, Restricted to Rs.150 per hospilisation or 1.5% of Sum insured ( whichever is higher) (Covered upto per hospitalization liit) drugs and consumables.($$)
Day care procedures-
i. Haemo-Dialysis
ii. Parenateral Chemotherapy
iii. Radiotherapy
iv. Eye Surgery
v. Lithotripsy ( kidney stone removal)
vi. Tonsillectomy
vii. D&C
viii. Surgery of Hydrocele
ix. Surgery of Prostrate
x. Few Gastrointestinal Surgery Covered up to SI xi. Genital Surgery
xii. Surgery of Nose
xii. Surgery of Throat
xiv. Surgery of Ear
xv. Surgery of Urinary System
xvi. Treatment of fractures / dislocation (excluding hairline fracture), Contracture releases and minorreconstructive procedures of limbs which otherwiserequire hospitalization.
xvii. Laparoscopic therapeutic surgeries that can bedone in a day care
Other benefitsAdditional Benefits that can be purchased for extra premium
Overall Sum Insured (SI) Rupees Overall Sum Insured (SI)
5,000 10,000 20,000 30,000Maternity & New Born benefits (**)
Maternity cover for up to 2 deliveries in the entirepolicy period ( Family floater only) Not Available Covered up to Rs.3,000 for Normal and Rs.5,000 for cesareanNew Born Baby Cover Not Available Covered up to SI from day 91 with no extra premium till next renewal
Personal accident ( Death )(&&)
Accidental Death ( only to Adults) Maximum equall 100% of Sum Assured and a minimum of Rs.10,000 per life available only to Adults.OPD
Covers ( ECG,x-ray,Hemoglobin,Blood sugar,Urea,Creatnine ) Upto Rs.500 (per cover under each Certificate of Insurance) in Network Hospital onlyAllowances
Wage Loss Allowances (subject to 48 hours hospitalisation) Rs.100 per day of hospitalization maximum of Rs.700 per cover under each Certificate of InsuranceTransport Allowance (In case of Inpatient Treatmentfor emergency cases only) Max upto 1000 per cover under each Certificate of Insurance and Max 600 Rs per hospitalisationBy Stander Allowance (Subject to 48 hours hospitalisation) Rs.50 per day max of Rs.350 per cover under each Certificate of InsuranceMeal Allowance ( Subject to 48 hours hospitalisation) Rs.30 per day maximum up to Rs.210 per cover under each Certificate of Insurance
Waivers available for Purchase30 day no claim/waiting period from policy inception
24 month waiting period from for Specific Exclusions Available to all groupsPre-existing disease exclusions waivers
(%%) Individual Cover 5,000 -30,000 and Family cover 10,000-30,000 / Family ( insured+spouse+upto 3 kids). Main member age at entry 18-65 years and dependents 3 months to 65 years.There is no exit age.
(^^^^^^^ ^ ) Per hospitalisation limit of 80% of sum insured. ($$) 7days Pre Hospitalisation and 15 Days Post Hospitalisation . (* *) Expenses related to premature delivery ,Pre and Post Hospitalisation would be part of overall maternity cover, (&&) Cover available to only member and his/her spouse. Age 18-65 years only.
- Duly filled claim form(s) stamped by group (main
policy holder) supported by Investigation test
reports, Original bills, receipts and discharge
certificate/card from the Hospital/ Doctor/Chemists
Doctor's referral letter advising hospitalization in
non-accident cases, the post mortem report (in
case of insured person’s death), First Information
Report (FIR) for medico-legal cases
- Details of any other insurance policy that may
respond to the claim.
We/TPA might request for any other documents or
information that we believe may be required.
Disclosures on Continuity
If a Primary Insured ceases to be Your member/
borrower during the Policy Period, then cover under
the Policy for that Primary Insured and his Dependants
(who are named as Insured Persons in the Schedule)
will immediately and automatically cease unless the
Primary Insured gives Us a written request prior to or
within 5 days of the date of cessation of employment,
to issue a new health insurance policy to himself and
his Dependents (who were named as Insured Persons
in the Schedule) for cover up to his Sum Insured under
the Policy, on payment of premium in full for the new
policy. The Primary Insured understands and agrees
that:
(i) the issue of a new policy shall be subject to Our underwriting requirements, as applicable from time to time, and We may obtain additional information before issuing a new policy;
(ii) We are not bound to continue all terms and conditions of the present cover under the Policy of the Primary Insured and his Dependents under the new policy, however for calculation of waiting periods including for pre-existing conditions under the new policy the time spent by Primary Insured and his Dependants under this Policy may be taken into account, provided new policy is taken without any break from this Policy. Coverage under the new policy shall be available only for the period for
which the premium has been received by Us;
(iii) We are not bound to continue the cover for the
Primary Insured or all his Dependents.
Nomination Facility: Primary Insured can, at the
inception or at any time before the expiry of the Policy,
make a nomination for the purpose of payment of
claims.
How to Buy Max Bupa Swasthya Pratham Micro Insurance Product1. The Micro Insurance Product is sold through all the
direct and indirect channels such as, Agency,
Corporate Agency, DST and Micro Insurance
Agents.
2. Every Customer will be assigned a unique customer
identification number on the Max Bupa system.
3. A Max Bupa proposal form to be completed after
the Customer provides the required information as
stated below :
• Insured’s name, date of birth, designation and address, as necessary.
• As above for all dependants to be covered by the policy.
• Any existing health insurance policy details and claims history, if applicable.
• Selection of Swasthya Pratham Micro Insurance Product sum insured, waivers and
additional cover. • Disclosure of any pre-existing medical
conditions with details. • Medical history report for applicant and
dependants, if necessary. • Signature and date on application, wherever
applicable.
4. All proposals accepted by Max Bupa are internally
processed and enrolled into the Max Bupa system,
and premium payments are cleared.
5. Where proposals are not accepted due to
unacceptable risk then customer too receive
communications from Max Bupa advising of the
same and specific reasons for the cover denied.
Swasthya Pratham - Micro Insurance ProductProduct benefit table
6 7
Overall Sum Insured (SI) Rupees
5,000 10,000 20,000 30,000Base Line Cover Benefits (%%)
In-patient treatment (^^^^^^^^^^^^^ ^^^^^^^ ) Doctors’ fees
Diagnostics Tests
Medicines, drugs and consumables
Intravenous fluids, blood transfusion,
injection administration charges
Intensive Care Unit charges
Anaesthesia, Blood, Oxygen,Operation Theatre Covered up to SI Charges, Surgical appliances
Radiotherapy, Cost of Prosthetic Devices,
implants
Medicines and Drugs, Diagnostic Materials and
X-ray, Dialysis, Chemotherapy
Nursing Expenses
Hospital Accommodation General Ward (Boarding Expense)Pre and post hospitalization expenses includingdoctor's consultation, diagnostics tests, medicines, Restricted to Rs.150 per hospilisation or 1.5% of Sum insured ( whichever is higher) (Covered upto per hospitalization liit) drugs and consumables.($$)
Day care procedures-
i. Haemo-Dialysis
ii. Parenateral Chemotherapy
iii. Radiotherapy
iv. Eye Surgery
v. Lithotripsy ( kidney stone removal)
vi. Tonsillectomy
vii. D&C
viii. Surgery of Hydrocele
ix. Surgery of Prostrate
x. Few Gastrointestinal Surgery Covered up to SI xi. Genital Surgery
xii. Surgery of Nose
xii. Surgery of Throat
xiv. Surgery of Ear
xv. Surgery of Urinary System
xvi. Treatment of fractures / dislocation (excluding hairline fracture), Contracture releases and minorreconstructive procedures of limbs which otherwiserequire hospitalization.
xvii. Laparoscopic therapeutic surgeries that can bedone in a day care
Other benefitsAdditional Benefits that can be purchased for extra premium
Overall Sum Insured (SI) Rupees Overall Sum Insured (SI)
5,000 10,000 20,000 30,000Maternity & New Born benefits (**)
Maternity cover for up to 2 deliveries in the entirepolicy period ( Family floater only) Not Available Covered up to Rs.3,000 for Normal and Rs.5,000 for cesareanNew Born Baby Cover Not Available Covered up to SI from day 91 with no extra premium till next renewal
Personal accident ( Death )(&&)
Accidental Death ( only to Adults) Maximum equall 100% of Sum Assured and a minimum of Rs.10,000 per life available only to Adults.OPD
Covers ( ECG,x-ray,Hemoglobin,Blood sugar,Urea,Creatnine ) Upto Rs.500 (per cover under each Certificate of Insurance) in Network Hospital onlyAllowances
Wage Loss Allowances (subject to 48 hours hospitalisation) Rs.100 per day of hospitalization maximum of Rs.700 per cover under each Certificate of InsuranceTransport Allowance (In case of Inpatient Treatmentfor emergency cases only) Max upto 1000 per cover under each Certificate of Insurance and Max 600 Rs per hospitalisationBy Stander Allowance (Subject to 48 hours hospitalisation) Rs.50 per day max of Rs.350 per cover under each Certificate of InsuranceMeal Allowance ( Subject to 48 hours hospitalisation) Rs.30 per day maximum up to Rs.210 per cover under each Certificate of Insurance
Waivers available for Purchase30 day no claim/waiting period from policy inception
24 month waiting period from for Specific Exclusions Available to all groupsPre-existing disease exclusions waivers
(%%) Individual Cover 5,000 -30,000 and Family cover 10,000-30,000 / Family ( insured+spouse+upto 3 kids). Main member age at entry 18-65 years and dependents 3 months to 65 years.There is no exit age.
(^^^^^^^ ^ ) Per hospitalisation limit of 80% of sum insured. ($$) 7days Pre Hospitalisation and 15 Days Post Hospitalisation . (* *) Expenses related to premature delivery ,Pre and Post Hospitalisation would be part of overall maternity cover, (&&) Cover available to only member and his/her spouse. Age 18-65 years only.
LITERATURESALES
PROSPECTUSSP
/SP/
01
1/V
.1.0
SWASTHYA PRATHAMMICRO INSURANCE PRODUCT
Disclaimer: This is only a summary of the product features and is for reference purpose only. The details of benefits
available shall be as described in the policy document, and will be subject to the policy terms, conditions and
exclusions. Please call our customer service if you require any further information or clarification.
Statutory Warning: Prohibition of rebates (under section 41 of Insurance Act 1938); no person shall allow or offer
to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance
in respect of any kind of risk relating to life or property, in India, any rebate of the whole or part of the commission
payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or
continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published
prospectus or the tables of the insurer. Any person making default in complying with the provision of this section
shall be punished with fine, which may extend to five hundred rupees.
What to do next
Phone: 1800 3010 3333 (Toll Free) or 011-3300 3333
Web: www.maxbupa.com
If you wish to know more about Max Bupa’s Swasthya Pratham Micro
Insurance Product and/or would like a personal quote, speak to our specially
trained sales team or your local advisor. They’ll take time to fully understand
your requirements and help you to select the right plan for you.
Max Bupa Health Insurance Company LimitedCorporate Office : 2nd Floor, Salcon Ras Vilas, D-1, District Centre, Saket, New Delhi 110017
Registered Office : Max House, 1 Dr. Jha Marg, Okhla, New Delhi 110020www.maxbupa.com
‘Max’, Max Logo are registered trademarks of Max India Limited“Bupa” and the HEARTBEAT logo are the registered service marks of the The British United Provident Association Limited
All these marks are being used under license by Max Bupa Health Insurance Company Limited.
Insurance is the subject matter of solicitation