HDFC ERGO Health - Maxima Plan

Objectives

MAXIMA is a unique product proposition and a glimpse into the future of Health Insurance.Maxima offers cover for Inpatient as well as Outpatient medical expenses on cashless basis within a high quality trusted Apollo DKV network. Reimbursement facility is also available for all Inpatient expenses and for Outpatient consultations.

Features

1.INDIA
S FIRST 360 DEGREE HEALTH PLAN Maxima offers cover for Inpatient as well as Outpatient medical expenses on cashless basis within a high quality trusted Apollo DKV network. Reimbursement facility is also available for all Inpatient expenses and for Outpatient consultations.
2.WIDE COVERAGE OPTIONS TO CHOOSE FROM Maxima offers coverage for Inpatient as well as Outpatient benefit on Individual basis as well as on Family Floater for family members namely spouse, dependent children and dependent parents.
3.WIDE INPATIENT HOSPITALIZATION COVER Maxima offers Rs. 3,00,000 cover for inpatient hospitalisation for Inpatient treatment, pre-post hospitalisation, daycare procedures, domiciliary treatment, daily cash for choosing shared accommodation, expenses for organ donor, emergency ambulance charges, daily cash for accompanying an insured child, maternity expenses and day 1 coverage. Maxima offers access to widest inpatient care network at over 4000 hospitals spread across the country.
4.ACCESS TO HIGH QUALITY TRUSTED NETWORK FOR OUTPATIENT COVER Maxima offers outpatient consultations on a cashless basis at a high quality Apollo DKV trusted network of providers. It also offers reimbursement for outpatient consultations at any other provider of your choice, upto a maximum limit. Maxima offers cover on Diagnostic tests, Pharmacy bills, Outpatient Dental treatment, Spectacles, Contact Lenses, and Annual Health Check-up, all within a high quality trusted Apollo DKV network.
5.OPTIONAL CRITICAL ILLNESS COVER Maxima offers you the flexibility to choose optional additional, Critical illness cover as per your needs. This provides for additional coverage against 8 specified critical illnesses and is always paid in addition to any medical expenses you may incur, as a lump sum benefit.
6.PRE-EXISTING CONDITIONS COVERED UNDER OUTPATIENT Maxima offers cover on any pre-existing conditions that require outpatient care, without any waiting period. In case of Inpatient coverage, pre-existing conditions will be covered after a waiting period of three years.
7.COMPREHENSIVE HEALTH CHECKUP Maxima offers an Annual Health Check-up that you may take across Apollo DKV
s high quality trusted network on a cashless basis. This is to ensure that you remain in good health, and are able to detect and begin treatment for any diagnosed diseases as early as possible, giving you the best chance for a full recovery.
8.LIFE LONG RENEWAL Maxima offers coverage starting from 91st day, with the maximum entry age being 65 years. The uniqueness of Maxima is that there is no maximum age of cover
you will benefit from our life long renewal policy.
9.CUMULATIVE BONUS AND CARRY FORWARD OF OPD BENEFITS For Inpatient treatment, Maxima offers a cumulative bonus of 10% for every claim-free year accumulating to a maximum of 50% of your inpatient sum insured. In event of claim, the cumulative bonus is reduced by 20% on the next renewal. For Outpatient treatment, Maxima offers the advantage to carry forward 50% of any unutilized Entitlement Certificates to next policy year (except Annual Health Check-up). This ensures more value for money for you and your family.
10.ENJOY THE ADVANTAGE OF TAX SAVINGS Maxima offers you tax savings under section 80D of IT act for the full premium amount. This makes Maxima a very wise investment, ensuring you and your family can enjoy India
s first 360 degree healthcare plan while increasing your savings via smart tax planning.

Advantages

1.This policy covers persons in the age group 91 days onwards. The maximum entry age is 65 years.
2.There is no maximum cover ceasing age in this policy.
3.The policy will be issued for a 1 year period.
4.This policy can be issued to an individual and/or family. The family coverage in on floater basis and the coverage will be available for two adults & two adults + upto 2 children.
5.The family includes spouse, dependent children and dependent parents.
6.The premium under floater coverage will be charged on the age of the eldest insured member.

Benefits

Outpatient Module We will issue Entitlement Certificate to the Insured Person for availing Outpatient benefits with the Network service provider.
1. Outpatient Consultations - Outpatient consultations (In Network or Non-Network) by a general Medical Practitioner(s) or a specialist Medical Practitioner(s).
2. Diagnostic Tests within specified Network - Outpatient diagnostic tests taken by the Insured Person from a Network diagnostic centre (not necessarily to be prescribed by Network Medical Practitioner).
3. Pharmacy within specified Network - Medicines purchased by the Insured Person from a Network pharmacy, provided that such medicines have been prescribed in writing by a Medical Practitioner (not necessarily to be Network Medical Practitioner).
4. Outpatient Dental Treatment within specified Network - Any necessary dental treatment taken by an Insured Person from a Network dentist provided that We will not pay for any dental treatment that comprises cosmetic treatment.
5. Spectacles, Contact lenses within specified Network - Either one pair of spectacles or contact lenses, provided that these have been prescribed for the Insured Person by a Eye specialist network Medical Practitioner(s).
6. Annual Health Check Up within specified Network - A health check-up for the Insured Person in a Network Hospital.
Inpatient Module
1. In-patient Treatment
covers hospitalisation expenses due to an illness or accident. We will pay for the medical expensesfor Room rent, boarding expenses, Nursing, Intensive care unit, Medical Practitioner(s), Anesthesia, blood, oxygen, operationtheatre charges, surgical appliances, Medicines, drugs and consumables, Diagnostic procedures, Cost of prosthetic &other devices or equipments if implanted internally during a Surgical Procedure
2. Pre- Hospitalisation - The Medical Expenses incurred in 30 days immediately before the Insured Person was hospitalised.It can be increased to 60 days if claim is intimated 5 days before hospitalisation.
3. Post-Hospitalisation - The Medical Expenses incurred in 60 days immediately after the Insured Person was dischargedpost Hospitalisation. It can be increased to 90 days if claim is intimated 5 days before hospitalisation.
4. Day-Care procedures
The Medical Expenses for 140 Day care procedures which do not require 24 hours hospitalisationdue to technological advancement.
5. Domiciliary Treatment - The Medical Expenses incurred by an Insured Person for availing medical treatment at his homewhich would otherwise have required Hospitalisation.
6. Organ Donor - The Medical Expenses for an organ donor
s treatment in the event of organ transplantation.
7. Emergency Ambulance
Expenses Upto Rs. 2000 per hospitalisation for utilizing ambulance service for transportingInsured Person to Hospital in case of an emergency or from one hospital to another if medical services required are notavailable.
8. Maternity Expenses
Medical Expenses for maternity including pre-natal and post-natal expenses after a waiting periodof 4 years.
9. Newborn baby
Optional Coverage for newborn from birth (day 1 - 90) for In-patient Treatment benefit, subject toacceptance of proposal and premium payment in full.
10. Daily Cash for choosing shared accommodation- Daily cash amount per day if the Insured Person is Hospitalised inShared Accommodation in a Network Hospital and hospitalisation exceeds 48 hrs.
11. Daily Cash for accompanying an insured child- Daily cash amount for 1 accompanying adult if insured child under 12years is hospitalised and hospitalisation exceeds 72 hrs.
Optional Benefit: Critical Illness benefit provides lumpsum benefit for listed Critical Illness. The benefit amount is payable once theCritical Illness is diagnosed during the policy period and the Insured Person survives 30 days after the diagnosis. This benefit can beopted on payment of additional premium. This benefit if opted is applicable to all family members on Individual Sum Insured Basisequivalent to Rs 300,000/-. This benefit will not be renewed beyond 70 years of age.

Sum Assured Details

Inpatient Sum Insured per policy of Rs 300,000, Outpatient Sum Insured per policy as mentioned in Schedule of benefits and Critical Illness (Optional Benefit) Sum Insured per insured Rs 300,000/-.

General Exclusions

1- All treatment within the first 30 days of cover except any accidental injury.
2- Any pre - existing condition will be covered after a waiting period of 3 years.
3- Expences arising from HIV or AIDS and related diseases.
4- Non - allopathic treatments,congenltal diseases,menatl disorder or Insanlty,cosmetic surgery and weight control treatments.
5- Abuse of intoxicant or hallucinogenic substance like drugs and alcohol.
6- Hospitalisation due to war or an act of war or due to a nuclear,chemical or biological weapon and radiation of any Kind.
7- Pregnancy,dental and external aids and appliances unless covered under the specific Easy Health Individual Insurance Plan mentioned above.
8- 2 years exclusion for specific diseases like cataract,hemia,hysterectomy,joint replacement,hydrocele.
9- Items of personal comfort and convenience
10- Experimental ,Investigative and unproven treatment device and pharmacological regimens.

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Frequently Asked Questions About Insurance

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What is health insurance? +

Health insurance is a type of coverage that pays for medical and surgical expenses incurred by the insured. It may also provide coverage for other types of health-related costs, such as prescription drugs, mental health services, and preventive care.

Why do I need health insurance? +

Health insurance helps protect you from high medical costs. It provides access to medical care when you need it, helping to pay for doctor visits, hospital stays, surgeries, prescription medications, and other health-related services.

What is a premium? +

A premium is the amount you pay for your health insurance every month. Depending on your plan, the premium may vary based on factors like age, location, and level of coverage.

What is a deductible? +

A deductible is the amount of money you must pay out-of-pocket before your health insurance starts covering your medical expenses. For example, if you have a deductible of $1,000, you must pay $1,000 out-of-pocket before your insurance starts covering your medical bills.

What are copayments and coinsurance? +

Copayment (copay): A fixed amount you pay for a covered health care service, typically when you get the service. Coinsurance: The percentage of the cost you pay for covered health services after you've paid your deductible. For example, if your coinsurance is 20%, you pay 20% of the bill, and the insurance company pays the remaining 80%.

What is an out-of-pocket maximum? +

The out-of-pocket maximum is the maximum amount you can spend on your health insurance. If you exceed this amount, your insurance company will pay 100% of your medical expenses.

What is the difference between in-network and out-of-network providers? +

In-network providers: Health care providers that have a contract with your health insurance plan to provide services at negotiated rates. Out-of-network providers: Providers that don't have a contract with your insurance plan. Services from these providers may cost more or not be covered at all.

What is a Special Enrollment Period (SEP)? +

The Special Enrollment Period (SEP) is a special time during the year when you can sign up for or make changes to your health insurance plan. If you miss this period, you may have to wait until the next one unless you qualify for a Special Enrollment Period (e.g., due to a life event like marriage or having a baby).

Can I keep my doctor with health insurance? +

If you have a preferred doctor, it’s important to check if they are in-network with your insurance plan. If they are not in-network, you may need to pay more out-of-pocket, or you may have to switch to another doctor who is in-network.

What is a Health Savings Account (HSA)? +

A tax-advantaged account for people with high-deductible health plans (HDHPs). The funds roll over from year to year and can be used for qualifying medical expenses.

What is a Flexible Spending Account (FSA)? +

A tax-advantaged account for people with low-deductible health plans (LDHPs). The funds roll over from year to year and can be used for qualifying medical expenses.

What is a Health Maintenance Organization (HMO)? +

An HMO is a type of health insurance plan that requires you to choose a primary care physician (PCP) and get referrals from them to see specialists. HMOs often have lower premiums and out-of-pocket costs but offer less flexibility in choosing providers.

What is a Preferred Provider Organization (PPO)? +

A PPO is a health insurance plan that offers more flexibility in choosing healthcare providers and doesn’t require referrals to see specialists. You can see any doctor, but you’ll pay less if you use in-network providers.

What is the difference between a Health Savings Account (HSA) and a Flexible Spending Account (FSA)? +

HSA: A tax-advantaged account for people with high-deductible health plans (HDHPs) The funds roll over from year to year and can be used for qualifying medical expenses. FSA: A tax-advantaged account for people with low-deductible health plans (LDHPs) The funds roll over from year to year and can be used for qualifying medical expenses.

What does the term "pre-existing condition" mean? +

A pre-existing condition is a medical condition that you had before you got your health insurance. It could include things like diabetes, high blood pressure, or heart disease.

Can I cancel my health insurance at any time? +

Yes, you can cancel your health insurance plan at any time. However, if you cancel outside the open enrollment period, you may not be able to get another plan until the next enrollment period unless you qualify for a Special Enrollment Period.

Are prescription drugs covered by health insurance? +

Many health insurance plans cover prescription medications, but the coverage may vary. Plans typically have a formulary, or list of covered drugs, and different drugs may have different levels of coverage, depending on whether they are generic, brand-name, or specialty drugs.

What is preventive care? +

Preventive care includes health services that help prevent illnesses, such as vaccinations, screenings, and annual checkups. Under the Affordable Care Act, most preventive services are covered by health insurance plans at no additional cost to the policyholder.

What should I do if my health insurance claim is denied? +

If your claim is denied, you can appeal the decision. Review the denial letter for reasons, contact your insurer for assistance, and file a written request for a hearing. If you win the appeal, you may be able to get a refund or other compensation.

How can I choose the best health insurance plan for me? +

When selecting a plan, consider factors like: Your health care needs (e.g., frequent visits, prescriptions) The plan’s network of doctors and hospitals The cost of premiums, deductibles, copays, and out-of-pocket maximums Coverage for specialized care or treatments Compare the different plans and benefits to find one that meets your needs.

What happens if I don't have health insurance? +

If you don’t have health insurance, you can still access some health care services, such as emergency care, in-network doctors, and in-network hospitals. You may be eligible for Medicaid, which provides some health care services at no cost to you.

What is life insurance? +

Life insurance is a contract between you and an insurance company, where you pay regular premiums in exchange for a lump sum payment (death benefit) to your beneficiaries upon your death.

What are the different types of life insurance? +

Term Life Insurance: Provides coverage for a specific period (e.g., 10, 20, or 30 years). If you pass away during this term, your beneficiaries receive the death benefit. It does not build cash value. Whole Life Insurance: Offers lifetime coverage with a death benefit and also builds cash value over time, which you can borrow against or use. Universal Life Insurance: A flexible policy that allows you to adjust the premiums and death benefit while also building cash value.

How much life insurance coverage do I need? +

The amount of coverage you need depends on factors like your income, debts, family needs, and long-term financial goals. A common rule is to have coverage worth 10 to 15 times your annual income, but this can vary based on your individual situation.

What is the difference between beneficiaries and policyholders? +

The policyholder is the person who owns the life insurance policy and pays the premiums, while the beneficiary is the person or group that receives the death benefit when the policyholder passes away.

Can I change my beneficiaries? +

Yes, you can change your beneficiaries at any time during the life of the policy, as long as the policy is in force and you follow the correct procedure with the insurance company.

What is the contestability period? +

The contestability period is the time during which you have the right to contest the decision of the insurer to pay the death benefit. This period varies depending on the type of life insurance policy and the insurer.

Does life insurance cover accidental death? +

Some life insurance policies include accidental death coverage, while others may require a separate rider for this benefit. Be sure to review your policy to understand what’s covered.

Can I cancel my life insurance policy at any time? +

Yes, you can cancel your life insurance policy at any time, provided you follow the correct procedure with the insurance company.

What is cash value? +

Cash value is the accumulated value of the life insurance policy that can be used to pay for expenses, such as medical bills or funeral expenses.

How do I borrow against cash value? +

You can borrow against the cash value of your life insurance policy, but it will need to be repaid, and any unpaid loan will reduce the death benefit.

What is the difference between whole life and universal life insurance? +

Whole life insurance provides coverage for a specific period (e.g., 10, 20, or 30 years) and builds cash value over time. Universal life insurance offers lifetime coverage with a death benefit and also builds cash value over time.

How are life insurance premiums determined? +

Life insurance premiums are based on factors like age, health, lifestyle (e.g., smoking), coverage amount, and type of policy. Generally, younger, healthier individuals pay lower premiums.

Can I borrow money from my life insurance policy? +

If you have a whole life or universal life policy, it may build cash value over time. You can borrow against this cash value, but it will need to be repaid, and any unpaid loan will reduce the death benefit.

What happens if I stop paying my life insurance premiums? +

If you stop paying premiums, your policy may lapse. For permanent policies like whole or universal life, the cash value may cover the premiums for a time, but eventually, if premiums are not paid, the policy will end.

What is auto insurance? +

Auto insurance is a contract between you and an insurance company that provides financial protection against damage or injury caused by accidents, theft, or other incidents involving your vehicle. It covers both liability and your vehicle's repair costs depending on the type of policy.

What types of auto insurance coverage are available? +

There are several types of auto insurance coverage, including liability, collision, comprehensive, uninsured/underinsured motorist, and additional coverage like roadside assistance and collision damage waiver.

How much auto insurance do I need? +

The amount of coverage you need depends on factors such as the value of your car, your driving habits, your state's legal requirements, and whether you own or lease your vehicle. A good starting point is to meet your state's minimum required coverage, but you may want additional coverage for added protection.

Can I cancel my auto insurance policy at any time? +

Yes, you can cancel your auto insurance policy at any time, provided you follow the correct procedure with the insurance company.

What is the difference between liability and comprehensive coverage? +

Liability coverage covers the damages and injuries caused by accidents, while comprehensive coverage also covers non-accident damages, such as theft or vandalism.

How do I choose the right auto insurance policy? +

When selecting an auto insurance policy, consider factors such as the type of coverage you need, your driving habits, the value of your vehicle, and your state's legal requirements.

What factors affect my auto insurance premium? +

Several factors impact your insurance premium, including: Your driving history (accidents, tickets), The make, model, and age of your car, Your location (accident rates in your area), Your age, gender, and marital status, The level of coverage you choose, Your credit score (in some states).

What is a deductible? +

A deductible is the amount you must pay out of pocket before your insurance policy starts to cover the remaining cost of repairs or claims. For example, if you have a $500 deductible and incur $2,000 in damages, you will pay $500, and your insurer will pay the remaining $1,500.

What is the difference between comprehensive and collision coverage? +

Collision coverage pays for repairs to your vehicle after a collision with another vehicle or object, regardless of who is at fault. Comprehensive coverage covers non-collision incidents, such as theft, vandalism, or damage from natural disasters.

Can I get uninsured/underinsured motorist coverage? +

Yes, uninsured/underinsured motorist coverage is available in some states. This coverage provides financial protection for you if another driver is uninsured or underinsured.

Is auto insurance required by law? +

Yes, in most states, you are required to have a minimum level of liability insurance. Some states also require additional coverage like Personal Injury Protection (PIP) or uninsured motorist coverage. The requirements vary by state, so it’s important to check your local laws.

What happens if I don’t have auto insurance? +

If you drive without insurance, you risk facing legal penalties, fines, and the possibility of your driver's license being suspended. If you're involved in an accident, you could be held responsible for the damages.

Can I add other drivers to my auto insurance policy? +

Yes, you can add other drivers, such as family members or friends, to your policy. However, their driving record and age may affect your premium. It's important to inform your insurer about all the drivers in your household.

What should I do if I get into an accident? +

If you're in an accident, follow these steps: Ensure safety by moving to a safe location if possible. Call the police and file a report. Exchange contact and insurance information with the other driver(s). Take photos of the accident scene, vehicle damage, and injuries. Notify your insurance company about the accident as soon as possible.

What is home insurance? +

Home insurance is a contract between you and an insurance company that provides financial protection against damage or loss caused by natural disasters, theft, or other incidents.

What types of home insurance coverage are available? +

There are several types of home insurance coverage, including flood, fire, burglary, and liability. You may also have coverage for water damage, mold, and other property damage.

How much home insurance do I need? +

The amount of home insurance coverage you need depends on the value of your property, the type of coverage you want, and your insurance provider. You may also need additional coverage for water damage, mold, and other property damage.

Can I cancel my home insurance policy at any time? +

Yes, you can cancel your home insurance policy at any time, provided you follow the correct procedure with the insurance company.

What is the difference between flood and fire coverage? +

Flood coverage covers damage caused by floods, while fire coverage covers damage caused by fires.

How do I choose the right home insurance policy? +

When selecting home insurance, consider factors such as the type of coverage you need, the value of your property, and your insurance provider.

What factors affect my home insurance premium? +

Factors such as the type of coverage you need, the value of your property, and your insurance provider can significantly impact your premium.