Apollo optima restore presentation

20 September 2018AMHI CONFIDENTIAL 2
Why Health Insurance ?

Current Scenario
20 September 2018 AMHI CONFIDENTIAL
12
16%
Is the compound rate at which the healthcare
industry is expected to grow till 2020
$ 150 billion
Is the size of healthcare sector today
$ 280 billion
Is the estimated size of healthcare sector by
2020

Estimated cost of treatment
20 September 2018AMHI CONFIDENTIAL 14

Individual Health Insurance :purchased on an individual basis.
Family Floater Health Insurance: one single policy takes care of the hospitalization
expenses of your entire family under one Sum Insured.
Name Relationship D . O . B Sum Insured (Rs.)
Mr. Shyam Sharma Self 18 . 7 . 1973 10 Lac
Mrs. Rani Sharma Spouse 17 . 6 . 1974 10 Lac
Rahul Sharma Son 16 . 5 . 2000 10 Lac
Richa Sharma Daughter 15 . 4 . 2007 10 Lac
Name Relationship D . O . B Sum Insured (Rs.)
Mr. Shyam Sharma Self 18 . 7 . 1973
10 LacMrs. Rani Sharma Spouse 17 . 6 . 1974
Rahul Sharma Son 16 . 5 . 2000
Richa Sharma Daughter 15 . 4 . 2007

 Self, Spouse, Dependent Children, Dependent Parents, Dependent Parent in laws
Individual Plan:
 Maximum 6 members can be insured under one individual plan.
 Maximum 4 adults can be insured under one individual plan
 Family Discount of 10% if 2 or more members are covered under the same individual
policy
Family Floater Plan:
 Maximum 6 members can be covered under one policy with permissible
combinations being 1A+1C, 1A+2C, 1A+3C, 1A+4C, 1A+5C, 2A, 2A+1C,
2A+2C,2A+3C,2A+4C
 Maximum 2 adults can be insured in one family floater plan
 Family discount not applicable under Family Floater plan Family discount not
applicable under Family Floater plan
Eligibility

Who can be insured
Minimum Maximum
Self 18 years 65 years
Adult Dependent 18 years 65 years
Child Dependent 5 years
(can be covered from 91st
day
onwards if either parent is
covered under this policy)
25 years (unmarried
and financially
dependent with no
independent source of
income)
Cover ceasing age: There is no cover ceasing age on renewals.

Premium Payment
.
Easy Health provides an
option to buy a plan for 2
years with a discount of
7.5% applied on the
combined premiums of the
1st & 2nd year.

Benefit Overview
The Policy pays for the benefits mentioned below:

In patient Treatment
 The Medical Expenses for:
 Room rent, boarding expenses,
 Nursing,
 Intensive care unit,
 Medical Practitioner(s),
 Anesthesia, blood, oxygen, operation theatre charges, surgical appliances,
 Medicines, drugs and consumables,
 Diagnostic procedures
 The Cost of prosthetic and other devices or equipment if implanted internally
during a Surgical Procedure.

Pre Hospitalisation
 The medical expenses incurred in the 60 days immediately before the
insured person was hospitalised, provided that:
i. Such Medical Expenses were in fact incurred for the same
condition for which the Insured Person’s subsequent
Hospitalisation was required, and
ii. We have accepted an in-patient hospitalisation claim under
benefit in-patient treatment.

Post Hospitalisation
 The medical expenses incurred in the 180 days immediately after
the insured person was discharged post hospitalisation provided
that:
i. Such costs are incurred in respect of the same condition for
which the insured person’s earlier hospitalisation was
required, and
ii. We have accepted an in-patient hospitalisation claim under
benefit in-patient treatment.

Day care Procedures
 Any medical treatment, and/or surgical procedure which is:
i) undertaken under General or Local Anaesthesia in a hospital/ day care centre in less
than 24 hrs because of technological advancement, and
ii) ii) which would have otherwise required hospitalization of more than 24 hours.
 Treatment normally taken on an out-patient basis is not included inProcedure or
surgery taken by the insured person as an inpatient for less than 24 hours.
 All Day care procedures are covered
Indicative list of procedures:
 Cataract
 Chemosurgery to the skin
 Operations on the tonsils and adenoids
 Hemorrhoids
 Lithotripsy
 Coronary angiography
Note: Pre & Post hospitalization expenses are covered under Day Care Procedures also

Domiciliary Treatment
 The medical expenses incurred by an insured person for medical
treatment taken at home, which otherwise would have required
hospitalisation
 Could not be transferred to a Hospital, or
 Hospital bed was unavailable
 The condition continues for at least 3 days
 We will not make any payment for Post-Hospitalisation
expenses but We will pay Pre-hospitalisation expenses upto
60 days in accordance with pre-hospitalisation benefit, and

Organ Donor
 The medical expenses for an organ donor’s treatment for the harvesting of
the organ donated, provided that:
i. The organ donor is any person whose organ has been made
available in accordance and compliance with “The Transplantation of
Human Organs Act, 1994 (amended)” and
ii. The organ donated is for the use of the Insured Person, and
iii. We will not pay the donor’s pre and post-Medical Expenses or any
other medical treatment for the donor consequent on the harvesting,
and
iv. We have accepted an in-patient hospitalisation claim under benefit
In-patient treatment.

Ambulance Cover
 Expenses incurred on an ambulance offered by a healthcare or
ambulance service provider used to transfer the Insured Person to the
nearest Hospital with adequate Emergency facilities for the provision
of health services, provided that:
i) Our maximum liability shall be restricted upto Rs 2,000 per
hospitalisation, and
ii) We have accepted an in-patient Hospitalisation claim.

Emergency Air Ambulance
 Available for sum insured of 10 lacs and above
 Emergency ambulance transportation by air
for emergency life threatening health
conditions which require immediate and rapid
ambulance transportation to the
hospital/medical centre that ground
transportation cannot provide .
 Amount payable in case of Air ambulance
facility shall be either the actual expenses or
Rs. 2.5 Lacs per hospitalization, whichever is
lower; upto basic sum insured limit for a year
 This benefit will be offered on reimbursement
basis

Daily Cash - Shared Accommodation
 Payable if the insured person is hospitalized in Shared Accommodation
 in a Network Hospital
 hospitalisation exceeds 48 hours
 The day of admission and discharge shall be counted.
Sum Insured (Rs) Limits (Rs)
3, 5, 10 & 15 Lacs 800 per day, max 6 days
20, 25 & 50 Lac 1000 per day, max 6 days

E-opinion in respect of Critical Illness
 On request of the Insured person diagnosed with a critical illness,
We will arrange for a second opinion from a medical practitioner
selected by the insured person from Our panel. This benefit can
be availed once in a policy year
 Critical Illness includes Cancer, Open Chest CABG, First Heart
Attack, Kidney Failure, Major Organ/Bone Marrow Transplant,
Multiple Sclerosis, Permanent Paralysis of Limbs and Stroke.

 Step 1: Please submit /courier duly filled claim form along with the copy of
all medical reports including investigation reports and discharge summary (if
any) at any branch office or to the head office .
 Step 2: Select Panel Doctor from whom you would prefer to take the e-
opinion. (Please call at 24X 7 Toll Free line to obtain the list of Our Panel
Doctors)
 Step 3: On receipt of the complete set of documents we will forward the
same to the concerned doctor.
 Step 4: The E-Opinion will be forwarded to the member within 7 working
days of the receipt of the complete set of documents
E- Opinoin Claim Procedure

Health Check-up
 We will reimburse Expenses
incurred on medical check up
subject to continuous year(s)
without any break in the
previous policy year(s).

Plan/SI 3 Lacs 5 Lacs 10 Lacs 15 Lacs 20/25/50 Lacs
Individu
al (Per
Person)
Not
Applicable
Upto a maximum of
Rs.1,500 per
insured person,
only once at the
end of a block of
every continuous
two policy years.
Upto a
maximum of
Rs.2,000 per
insured person
at the end of
each year at
renewal.
Upto a maximum
of Rs.4,000 per
insured person,
at the end of
each year at
renewal
Upto Maximum of
Rs. 5000 per
Insured
Person, at the end
of each year at
renewal
Floater
(Per
Policy)
Not
Applicable
Upto a maximum of
Rs.2,500 per policy,
only once at the
end of a block of
every continuous
two Policy Years.
Upto a
maximum of
Rs.5,000 per
policy at the
end of each
year at
renewal
Upto a maximum
of Rs.8,000 per
policy, at the end
of each year at
renewal.
Upto a Maximum
of Rs. 10,000 per
policy,
at the end of each
year at renewal.
Payable irrespective of claims
Health Check-up

Why the new Restore Scores better?
Old Restore New Restore
5-June-2018

Why Optima Restore Scores better?
Family A purchases Optima Restore Family Floater Product 3 Lacs Sum Insured
Family B purchases Traditional Health Family Floater Product 3 Lacs Sum Insured
Why Optima Restore Scores better?

Scenario Claim
Payable
Insured (A) undergoes angioplasty consumes full
sum insured and multiplier benefit (if any).
Restore
Sum
Insured is
activated
After 2 months ( in the same policy year) Insured
(A ) again undergoes CABG procedure
Insured A ( in the same policy year) hospitalised due
to injuries sustained in an accident
Insured (A) under goes Renal transplant ( in the
same policy year).
Claim not payable for
similar illness or
condition
similar illness or
condition
Claim payable for
dissimilar illness or
condition upto restore
sum insured
Claim payable for
dissimilar illness or
condition upto restore
sum insured
Restore Benefit – Individual plan

How Restore Benefit Works - Individual
Scenario SI=5lac, Multiplier benefit 2.5 lac Claim
Payable
Insured (A) undergoes angioplasty
Claims = 2 lac
Claim paid = 2lac
Restore Sum
Insured is
activated
after claim
payment
Claims =1.5lac
Claim paid=1.5lac
Claims=8lac
Claim paid=7.5lac
Claim is now payable even
for similar illness or
condition
Claim is now payable even
for similar illness or
condition
Single claim size cannot
exceed sum of base SI and
Multiplier benefit(if any)
In this case 5+2.5=7.5 lac

How Restore Benefit Works - Floater
Scenario
(Family consisting of Insured A & Insured B)
SI=5 lac, Multiplier Benefir 2.5 lac
Claim
Payable
Insured A undergoes angioplasty
Claims: 2 lac
Claim paid: 2 lac
Restore Sum
Insured is
activated
after claim
payment
Claims: 1.5lac
Claim paid: 1.5 lac
Insured B ( in the same policy year) undergoes
angioplasty procedure
Claims 1 lac
Claims paid: 1lac
Insured A ( in the same policy year) hospitalised
due to injuries sustained in an accident
Claims=8lac
Claim paid=7.5lac
Claim is now payable for
similar illness or condition
for same insured member
Claim is now payable for
Claim also payable for other
insured member for similar
illness/condition
Claim also payable for other
illness/condition

Scenario
(Family consisting of Insured A & Insured B)
Claim Payable
Insured A undergoes angioplasty consumes full sum
insured and multiplier benefit (if any).
Restore Sum
Insured is
activated
After 2 months ( in the same policy year) Insured (A )
again undergoes CABG procedure
Insured B ( in the same policy year) undergoes
angioplasty procedure ( Full SI available for same
procedure)
Insured A ( in the same policy year) undergoes Renal
procedure,
Claim payable for other
illness/condition
Claim payable for other
illness/condition
Claim payable for same
insured dissimilar illness or
condition
Claim payable for same
insured dissimilar illness or
condition
Restore Benefit – Floater plan

Restore Benefit- Important points
 Restoration of Sum Insured will be automatically triggered, when the first claim is submitted and
paid by the company .
 Basic sum insured will be re-instated only once in a policy year.
 Restore Sum Insured can be used for only future claims made by the Insured Person and also
against any claim for an illness/disease (including its complications) for which a claim has been
paid in the current policy year.
 If the restore sum insured is not utilized in a policy year, it will not be carried forward to any
subsequent policy year.
 Restore Benefit will be triggered automatically. Endorsement will be sent to customer once
restore benefit will be triggered.

Previous Restore Benefit Wording New Restore Benefit Wording
If the Basic Sum Insured and Multiplier Benefit (if any) is exhausted due to claims made
and paid during the Policy Year and accepted as payable, then it is agreed that a Restore
Sum Insured (equal to 100% of the Basic Sum Insured) will be automatically available for
the particular Policy Year, provided that:
a) The Restore Sum Insured will be enforceable only after the Basic Sum Insured inclusive
of the Multiplier Bonus under Section 4 have been completely exhausted in that year; and
b) The Restore Sum Insured can be used for claims made by the Insured Person in respect
of the benefits stated in Section 1;
c) The Restore Sum Insured can be used for only future claims made by the Insured Person
d) No Multiplier Bonus under Section 4 will apply to the Restore Sum Insured;
e) The Restore Sum Insured will only be applied once for the Insured Person during a Policy
Year; f) If the Restore Sum Insured is not utilized in a Policy Year, it shall not be carried
forward to any subsequent Policy Year.
In case Family Floater Policy, Restore Sum Insured will be available for all Insured Persons
in the Policy.
Specific Exclusion to Restore Benefit
Illness/Disease for which a claim has already been paid to the Insured Person in the
current Policy Year under Section 1. IMPORTANT: In a Family Floater the Illness or disease
will be covered in case a claim is made by any other Insured Person other than the Insured
Person who has already claimed for that Illness or disease.
Instant addition of 100% Basic Sum Insured on complete
or partial utilization of Your existing Policy Sum Insured
and Multiplier Benefit (if applicable) during the Policy Year.
The Total amount (Basic sum insured, Multiplier benefit
and Restore sum insured) will be available to all Insured
Persons for all claims under In-patient Benefit during the
current Policy Year and subject to the condition that single
claim in a Policy Year cannot exceed the sum of Basic Sum
Insured and the Multiplier Benefit (if applicable).
Conditions for Restore benefit:
a. The Sum Insured will be restored only once in a
Policy Year.
b. If the Restored Sum Insured is not utilized in a
Policy Year, it will expire.
In case of a Family Floater Policy, Restore Sum Insured will
be available on floater basis for all Insured Persons in the
Policy.
.

 Available for every claim free year
 Sum Insured increased by 50%
accumulated maximum up to
100% of SI
 In the event of Claim, Multiplier
Benefit is reduced by 50% of basic
Sum Insured at the time of
renewal.
Multiplier Benefit

If Insured Person opts for Optima Restore Policy with 5 Lacs Sum Insured
& does not make a claim during policy duration. Multiplier Benefit will be
functional as follows-:
Year 1 Year 2 Year 3 Year 4
Base Sum Insured 500,000 500,000 500,000 500,000
Multiplier Benefit NA 250,000 500,000 500,000
Total Amount
(At beginning of the
year)
500,000 750,000 10,00,000 10,00,000
Multiplier benefit- Without Claim

If Insured Person opts for Optima Restore Policy with 5 Lacs Sum Insured
& claimed in 3rd
year. Multiplier Benefit will be functional as follows-:
Year 1 Year 2 Year 3 Year 4 Year 5
Base Sum Insured 500,000 500,000 500,000 500,000 500,000
Multiplier Benefit NA 250,000 500,000 250,000 500,000
Total Amount
(At beginning of
the year) 500,000
750,000 10,00,000 750,000 10,00,000
Multiplier Benefit- With claim

Rider (Optional)
• Critical Advantage Rider

Critical Advantage Rider (Optional)

Listed major illnesses covered

Critical Advantage Rider – Benefits
A rider that covers planned treatment abroad for listed major illnesses.
Sum Insured Option
$250,000/$500,000
Sum Insured Option
$250,000/$500,000

Eligibility
 This rider will be offered if base policy Sum Insured is Rs. 10 lacs & above
 Offered on individual sum insured basis
Rider can be opted by dependents only if primary insured also opts for the same.
 Rider not offered to NRI/ PIO. It is allowed only for Indian Citizens
The relationships allowed will be as defined in base policy
 The Sum Insured of the dependent insured members should be equal to or less
than the Sum Insured of the primary insured member
 Sum insured of dependent parents must be the same
 Sum Insured for all the children must be same

 30 days waiting period
 2 year specific disease waiting period like cataract, hernia, joint
replacement surgeries and surgery for hydrocele
 Pre-existing Diseases will be covered after a waiting period 36
months
 HIV, AIDS and related disease
 External congenital disease
 Artificial limb and external devices
 Cosmetic treatment
 Items of personal comfort and convenience
 Maternity
Please refer to Policy wording for complete set of exclusions.
Major Exclusions

Health Advisory Benefit
 Lump sum benefit of Rs.
5000 if the insured takes
treatment in a network
hospital recommended by
Apollo Munich
 Amount would be credited to
customer`s account only after
the cashless has been
approved

Stay Active- Renewal Discount
 Walk and earn a renewal discount on you
premium!
 Earn upto 8% of renewal discount per policy in
case of Floater plans and per person in case of
individual plan.
 Stay Active discount Grid
 How to use- Simply download our mobile app,
register to track steps
Average Step Target Renewal
Discount
5000 or below 0%
5001 to 8000 2%
8001 to 10000 5%
Above 10000 8%

Stay Active illustration for individual plan
Policy start date 1st Jan 2015
Policy Tenure 1 year
Plan Details Optima Restore 15 Lacs Individual plan, Geography- Delhi
Member Age 48 years
Renewal Premium ( 1st
Jan 2016) Rs. 19229 + taxes
Renewal Discount due Rs. 1538 ( 8% renewal discount0
Premium paid at renewal Rs. 17691 + taxes
Time Durations
Time Interval
Policy start date- 90
Day 91-180 days 181-270 days 271-300 days
Time interval from RSD 1st
Jan-31st
March 1st
April-29th
June
30th
June- July-27th
Sept
28th
Sept -28th
October
Date on which discount is credited 1st
April 30th
June 28th
Sept 29th
November
Average steps taken each time
interval 11000 10098 11500 12000
Stay active discount % applicable 2% 2% 2% 2%
Cumulated renewal discount %
earned by the customer at the end
of policy tenure 8%

Stay Active illustration for floater plan
Policy start date 1st Jan 2015
Policy Tenure 1 year
Plan Details Optima Restore15 Lacs floater (2+0) plan, Geography- Delhi
Highest Member Age 48 years
Renewal Premium ( 1st
Jan 2016) Rs 34003.+ taxes
Renewal Discount due Rs. 2465 ( 7.25% renewal discount0
Premium paid at renewal Rs..31538 + taxes
Time Durations
Time Interval Policy start date- 90 Day 91-180 days 181-270 days 271-300 days
Time interval from RSD 1st
Jan-31st
March
1st
April-29th
June
30th
June- July-27th
Sept
28th
Sept -28th
October
Date on which discount is
credited 1st
April 30th
June 28th
Sept 29th
November
average steps taken in each time
interval by member 1 10100 11000 10000 10000
Average steps taken by member
2 8000 10490 12000 11000
Combined average of Member 1
and 2 9050 10745 11000 10500
Discount % applicable 1.25% 2% 2% 2%
Cumulated renewal discount %
earned on the policy at the end of
policy tenure 7.25%

Stay Active renewal discount calculation
• In an individual policy, the average step count would be calculated
per adult member and in a floater policy it would be an average of all
adult members covered. Dependent children covered either in
individual or floater plan will not be considered for calculation of
average steps.
• In individual policies the discount percentage (%) would be applied
on premium applicable per insured member (Dependent Children
are not eligible for this stay active discount in an individual policy)
and in a floater policy it would be applied on premium applicable on
policy.
• The mobile app must be downloaded within 30 days of the policy
risk start date to avail this benefit. The average step count
completed by an Insured member would be tracked on this mobile
application.

Free look cancellation
 Free Look period of 15 days is offered from the date of receipt
of the Policy document to review the terms and conditions of
this Policy.
 Free look cancellation is allowed only if no claim has been
made under the Policy.
 Free look provision is not applicable at the time of renewal of
the Policy
 Refund of premium after adjusting amount spent on any
medical check-up, stamp duty charges and proportionate risk
premium.

Portability
 Comparable health insurance plans
 The credit gained is applicable to:
oGeneral waiting period of 30 days
o 2 year specific disease exclusion
o Waiting periods for coverage of pre-existing conditions
 In case of accumulated bonus:
o Option 1: Increase the SI only up to the sum of SI+CB in previous
policy (or the next higher SI on offer under new policy)
o Option 2: Avail SI similar to SI in previous policy
oCB will not be ported

Sum insured enhancements provision
 Basic sum insured can be enhanced only at the time of
renewal
 If the insured enhances the basic sum insured one grid up, no
fresh medicals shall be required. In cases where the basic sum
insured enhanced is more than one grid up, the case shall be
subject to medicals.
 In case of enhancement in the basic sum insured waiting
period will apply afresh in relation to the amount by which the
basic sum insured has been enhanced.

Grace Period
 Policy provides a provision of 30 day grace period from the date
of expiry to renew the policy without lose of continuity benefits .
 Any claim incurred during break-in period is not be payable
under this policy..
 Any disease/ condition contracted during the grace period will
not be covered and will be treated as a pre-existing condition.

As per Section 80D –
• An assesse is entitled to a deduction
of Rs.25,000 in respect of medical
premium paid on the health of
himself, his spouse and children. If
any of them is a senior citizen, then
he shall be entitled to a maximum
deduction of Rs.50,000 as a whole.
• In addition thereto, if he
pays insurance premium on the
health of his parents,
whether dependent or not, he will be
entitled to additional deduction of
Rs.50,000
Section 80-D

Premium Grid
• The premium will be computed basis the city of residence
provided by the insured person in the application form. The
premium that would be applicable zone wise and the cities
defined in each zone are as under:
– Delhi NCR/Mumbai MMR- Delhi, Gurgaon, Noida, Faridabad,
Ghaziabad, Greater Noida ,Mumbai, Navi Mumbai , Thane,
Kalyan, Dombivali, Bhayandar, Ulhasnagar, Bhiwandi,
Vasai,Virar
– Rest of India- All other cities

 On the basis of above mentioned details calculate premium for
Individual plan
Illustration for 1 year (Individual)
Insured Member Relationship Age (Yrs.) Sum Insured
(Lakhs)
City of
Residence
Mr. Raghav
Sharma
Self 34 10.00
DelhiMrs. Aruna Sharma Spouse 30 10.00
Seher Sharma Son 6 10.00
Insured Member Premium (Rs.)
Mr. Raghav Sharma 9342
Mrs. Aruna Sharma 9342
Seher Sharma 6768
Total 25452
10% family discount 2545.2
Net premium 22906.8
GST@18% 4123
Gross Premium 27030 (Round off)

On the basis of above mentioned details calculate
premium for Individual plan
Illustration for 1 year (Individual) with CA Rider
(Lakhs)
CA Rider
Insured ($)
City of
Residence
Mr. Raghav Sharma Self 34 10.00 250000
HyderabadMrs. Aruna Sharma Spouse 30 10.00 250000
Seher Sharma Son 6 10.00 250000
Insured Member Premium (Rs.) CA Premium (Rs.)
Mr. Raghav Sharma
8996 7767
Mrs. Aruna Sharma
8996 7767
Seher Sharma
6518 4833
Total 24510 20367
10% family discount 2451 2036.7
Grand Total 22059 18330.3
Net premium 40389
GST @18% 7270
Gross Premium 47659(Round off)
 On the basis of above mentioned details calculate premium for Individual plan with CAR option

Illustration for 2 year (Individual)
(Lakhs)
City of Residence
Mr. Raghav
Sharma
Self 32 10.00
ChennaiMrs. Aruna
Sharma
Spouse 28 10.00
Seher Sharma Son 6 10.00
Mr. Raghav Sharma 8996
Seher Sharma 6518
Total 24510*2=49020
2 years discount (7.5%) 3676.5
Total after 2 years discount (7.5%) 45343.5 (round off)
10% family discount 4534.35
Net premium 40809.15
GST @18% 7345.64
Gross Premium 48155
 On the basis of above mentioned details calculate premium for Individual plan

 On the basis of above mentioned details calculate premium for Individual plan with CAR option
Illustration for 2 year (Individual) with CA Rider
(Lakhs)
CA Rider
Insured ($)
City of
Residence
Mr. Raghav Sharma Self 34 10.00 500000
GurgaonMrs. Aruna Sharma Spouse 30 10.00 500000
Seher Sharma Son 6 10.00 500000
Insured Member Premium (Rs.) CA Premium(Rs.)
Mr. Raghav Sharma 11197*2 8947*2
Mrs. Aruna Sharma 11197*2 8947*2
Seher Sharma 8112*2 5490*2
Total 61012 46768
2 Years Discount(7.5%) 4575.9 3507.6
Total after 2 Years discount 56436.1 43260.4
10% family discount 5643.61 NA
Grand Total 50792.49 43260.4
GST@18% 16929
Gross Premium 110982 ( Round Off)

premium for floater plan
Illustration for 1 year (Floater)
(Lakhs)
City of Residence
Mr. Raghav
Sharma
Self 34
10.00 MumbaiMrs. Aruna
Sharma
Spouse 30
Seher Sharma Son 6
Mr. Raghav Sharma
15425Mrs. Aruna Sharma
Seher Sharma
10% family discount Nil
Net premium 15425
GST@18% 2777.
Gross Premium 18202 (Round Off)
 On the basis of above mentioned details calculate premium for Family Floater plan

Illustration for 1 year (Floater) with CA Rider
(Lakhs)
CA Rider
Insured ($)
City of
Residence
Mr. Raghav
Sharma
Self 34
10.00
250000
Bengaluru
Mrs. Aruna
Sharma
Spouse 30 250000
Seher Sharma Son 6 250000
Mr. Raghav Sharma
14853
7767
Seher Sharma 4833
Total 14853 20367
10% family discount NA NA
Grand Total 14853 20367
Net premium 35220
GST @18% 5980.35
Gross Premium 41560 (Round Off)
 On the basis of above mentioned details calculate premium for Family Floater plan with CAR option

 On the basis of above mentioned details calculate premium for Family Floater plan
Illustration for 2 year (Floater)
(Lakhs)
City of Residence
Mr. Raghav
Sharma
Self 32
10.00 HyderabadMrs. Aruna
Sharma
Spouse 28
Seher Sharma Son 6
Mr. Raghav Sharma
14853*2=29706Mrs. Aruna Sharma
Seher Sharma
2 years discount (7.5%) 2257.95
Total after 2 years discount (7.5%) 27478.05
10% family discount NIl
GST@18% 4946

Illustration for 2 year (Floater) with CA Rider
(Lakhs)
CA Rider
Insured ($)
City of
Residence
Mr. Raghav
Sharma
Self 34
10.00
250000
Navi Mumbai
Mrs. Aruna Sharma Spouse 30 250000
Seher Sharma Son 6 250000
Mr. Raghav Sharma
18041*2= 36082
7767*2
Mrs. Aruna Sharma 7767*2
Seher Sharma 4833*2
2 year discount (7.5%) 2706.15 1527.5
Total After 2 Year discount 33376 ( Round Off)
18839.5
10% family discount NA NA
Grand Total 33376 18839.5
Net premium 52215.5
GST@18% 9399
 On the basis of above mentioned details calculate premium for Family Floater plan with CAR option

PPC Process Flow
PA calls the customer , briefs on
PC requirement, process and provides
ption to choose from.
TPA calls the customer , briefs on
PPC requirement, process and provides
option to choose from.
Customer confirms the preferred DC,
date and time of visit to caller.
Customer confirms the preferred DC,
date and time of visit to caller.
Customer undertakes the tests as per
schedule date & time through Cashless
model. No payment to be made at DC.
Customer undertakes the tests as per
schedule date & time through Cashless
model. No payment to be made at DC.
DC forwards all the reports to TPA.
TPA does the QC and forwards to
AMHI
DC forwards all the reports to TPA.
TPA does the QC and forwards to
AMHI
AMHI does the medical underwriting
and confirms for issuance of the policy.
AMHI does the medical underwriting
and confirms for issuance of the policy.
For Rejected cases, 100% PPC cost
will be deducted from premium refund
For Rejected cases, 100% PPC cost
will be deducted from premium refund
PPC process is
CASHLESS to the
customer and 100%
will be borne by AMHI
for Accepted
application.

Pre-policy checkup grid- Rest of India
Optima Restore-PPC Grid- Rest of India
Basic Sum Insured (Rs.)
Age Group 300,000 500000 10,00,000
15,00,000; 20,00,000;
25,00,000; 50,00000
<18 years
Nil Nil Nil Nil
18-45 years
Nil Nil Nil
Verification
call*/MER, FBS,
TMT, Lipids, Sr
creatinine, LFT, Sr
uric acid, USG Abd
46-55 years
MER, FBS, ECG, TC,
Sr creatinine
MER, FBS, ECG, TC, Sr
creatinine
MER, FBS, TMT, Lipids, Sr
creatinine, LFT, Sr uric
acid, USG Abd
MER, FBS, TMT,
Lipids, Sr creatinine,
LFT, Sr uric acid,
USG Abd
56-60 years
MER, FBS, ECG,
Lipids, Sr creatinine
MER, FBS, TMT, Lipids,
Sr creatinine, LFT, Sr uric
acid, USG Abd
acid, USG Abd
MER, FBS, TMT,
Lipids, Sr creatinine,
LFT, Sr uric acid,
USG Abd
61-65 years
MER, FBS, ECG, 2D
ECHO, Lipids, Sr
acid, USG Abd
MER, FBS, ECG, 2D
ECHO, Lipids, Sr
acid, USG Abd
MER, FBS, ECG, 2D
ECHO, Lipids, Sr
acid, USG Abd
MER, FBS, ECG, 2D
ECHO, Lipids, Sr
creatinine, LFT, Sr
uric acid, USG Abd
*Verification call –for standalone OR ,If in combination with any product, then PPC grid would apply

Pre-policy checkup grid- South India
Optima Restore-PPC Grid- Southern Region
Basic Sum Insured ( Rs.)
Age Group 300,000 500000 10,00,000 15,00,000; 20,00,000;
25,00,000; 50,00000
<18 years Nil Nil Nil Nil
18-45 years Nil Nil Nil Verification Call*/ MER,
FBS, TMT, Lipids, Sr
acid, USG Abd)
46-50 years Nil Nil MER, FBS, TMT, Lipids, Sr
creatinine, LFT, Sr uric acid,
USG Abd
acid, USG Abd)
51-55 years MER, FBS, ECG, TC,
Sr creatinine
MER, FBS, ECG, TC, Sr
creatinine
USG Abd
acid, USG Abd
56-60 years MER, FBS, ECG,
Lipids, Sr creatinine
USG Abd
USG Abd
acid, USG Abd
61-65 years MER, FBS, ECG, 2D
ECHO, Lipids, Sr
creatinine, LFT, Sr
uric acid, USG Abd
MER, FBS, ECG, 2D
ECHO, Lipids, Sr creatinine,
LFT, Sr uric acid, USG Abd
MER, FBS, ECG, 2D ECHO,
Lipids, Sr creatinine, LFT, Sr
uric acid, USG Abd
MER, FBS, ECG, 2D
ECHO, Lipids, Sr
acid, USG Abd
*Verification call –for standalone OR ,If in combination with any product, then PPC grid would apply

Pre policy checkup Grid- CA Rider ( Pan India)
Age/ SAR > 10 L
<18 years Nil
18-45 years
Cat 6 (MER, FBS, TMT, Lipids, Sr creatinine, LFT, Sr uric
acid, USG Abd)
46-50 years
acid, USG Abd)
51-55 years
acid, USG Abd)
56-60 years
acid, USG Abd)
61-65 years
Cat 7 (MER, FBS, ECG, 2D ECHO, Lipids, Sr creatinine,
LFT, Sr uric acid, USG Abd)

Rejections
 Members with any of the following conditions/ ailments or history of the same, may be rejected subject to
underwriting:
 Diabetes Mellitus or Impaired glucose tolerance
 Coronary Artery Disease (Angioplasty/Coronary bypass/Heart attack)
 Congestive Heart Failure/ Conduction Abnormalities of Cardiac System/ Pace maker implantation
 Cerebrovascular Accident (Stroke)
 Malignancy or Cancer (Leukemia, Sarcoma, etc)
 Auto Immune Diseases (Rheumatoid Arthritis, SLE, Ankylosing spondylitis etc.)
 Renal Transplant/ Congenital disorders of Renal System
 Cirrhosis (Alcoholic/Nonalcoholic)
 Multiple Sclerosis
 Epilepsy
 Mental Retardation
 Genetic Disorders
 Psychiatric disorder
 Renal failure /Chronic renal disorder/ ESRD (End stage renal disorder)
 Paralysis
 Inflammatory bowel disease (Crohn’s disease and Ulcerative colitis)
 Pregnant female life from the second trimester up to 1 month of child birth.
PS: This list is for illustrative purpose, and not exhaustive.

HospitalizationHospitalization
Network
Hospital
Network
Hospital
Non Network
Hospital
Non Network
Hospital
Either Cashless
or
Re-imbursement
Either Cashless
or
Re-imbursement
Only Re-
imbursement
Only Re-
imbursement
Claim type

Planned Hospitalization
(7 days prior to
Admission)
Planned Hospitalization
(7 days prior to
Admission)
Emergency
Hospitalization
(As soon as Possible)
Emergency
Hospitalization
(As soon as Possible)
Fax / Email / Call / LetterFax / Email / Call / Letter
Apollo MunichApollo Munich
Intimation AcknowledgementIntimation Acknowledgement
Intimation

Pre-Authorization
Fills a Preauthorization Form
in the Hospital
Fills a Preauthorization Form
in the Hospital
Insured Approach Apollo Munich Network HospitalInsured Approach Apollo Munich Network Hospital
Hospital faxes papers to Apollo MunichHospital faxes papers to Apollo Munich
Apollo Munich – Authorize/Rejects/QueryApollo Munich – Authorize/Rejects/Query
Treatment in Network HospitalTreatment in Network Hospital
Discharge from the HospitalDischarge from the Hospital

Claim Re-imbursement
Claim Submission in Apollo Munich OfficeClaim Submission in Apollo Munich Office
Acknowledgement Letter by Apollo MunichAcknowledgement Letter by Apollo Munich
SettledSettled
NEFT transfer/ Cheque will be sent
to the Customer
NEFT transfer/ Cheque will be sent
to the Customer
Claim ClosureClaim Closure
QueryQuery RepudiatedRepudiated
Query Not RepliedQuery Not Replied Query RepliedQuery Replied

Service Standard - Claims
Particulars TAT
Preauthorization 2 Hrs
Query 5 days
Rejection 5 days
Claim reimbursement 21 days
Closure After 2 reminders at the
interval of
15 days

Contact Details
Hyderabad Hub & Gurgaon Hub
Toll Free - 1800-102-0333
Fax - 1800-425-4077
E-mail- customerservice@apollomunichinsurance.com
Address :
Hyderabad Hub
Claims Department
Apollo Munich Health
Insurance Co Ltd
Ground Floor, Srinilaya –
Cyber Spazio
Road No. 2,
Banjara Hills
Hyderabad-500034
Address :
Gurgaon Hub
Claims Department
Apollo Munich Health
Insurance Co Ltd
2nd & 3rd Floor, iLABS
Centre, Plot No. 404-405,
Udyog Vihar, Phase-III,
Gurgaon-122016,
Haryana

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