Future Generali Health Insurance

There is no upper limit on the number of claims during the policy period. However, the total cumulative claim amount cannot exceed the Policy Sum Insured, unless the chosen plan has a Sum Insured Refill benefit, which provides additional coverage even after filing a claim.

The minimum age required for entry is 1 day. There is no limit of Maximum age for entry. Children will be covered as dependents up to 25 years of age. There is no exit age in this policy.

In case of an Individual policy, each Insured person under the policy will have a separate sum insured for them. Individual plan can be bought for self, lawfully wedded spouse, children, parents, siblings, parent in laws, grandparents and grandchildren, son in-law and daughter in-law, uncle, aunty, nephew & niece.

• Vital Plan : Self, spouse, dependent children and dependent parents.Children will be covered as dependents up to 25 years of age.
• Superior and Premiere Plan : Self, spouse, dependant or non-dependent children, dependent or non-dependent parents, Dependent Siblings, daughter in law, son in law, parents in law, grandparents and grandchildren.

When an insured is hospitalized and stays in hospital for more than 24 hours solely for receiving treatment it is termed as inpatient treatment. Out-patient treatment is when insured visits a clinic/hospital or a consultation room for diagnosis and treatment based on the advice of medical practitioner. In out-patient hospitalization patient is not admitted under a day care or as an in-patient.

Hospitalization under Ayurveda, Unani, Siddha, or Homeopathy (AYUSH ) are covered provided that the treatment has been undergone in a government hospital or in any institute recognized by government and / or accredited by Quality Council of India / National Accreditation Board on Health for that Alternative treatment.

Future Generali under this policy will pay the Reasonable and Customary Charges incurred for an organ donor’s treatment for the harvesting of the organ donated provided that :

• The organ donor is any person whose organ has been made available in accordance and in compliance with the Transplantation of Human Organs Act, 1994 and the organ donated is for the use of the Insured Person;
• We will not pay the donor’s screening expenses or pre and post hospitalisation expenses or for any other medical treatment for the donor consequent on the harvesting;
• We have accepted claim under Hospitalisation medical expenses for the Insured Person and the Insured Person has been Medically Advised to undergo an organ transplant;
• Costs directly or indirectly associated with the acquisition of the donor’s organ will not be covered.

If an Insured Person suffers an Illness or Injury during the Policy Period in respect of which a claim has been admitted under Hospitalisation medical expenses then at the Insured Person’s request We will arrange a maximum of two e-opinions (in a Policy Year) from a Medical Practitioner selected by the Insured Person from Our panel. The e-opinion will be based only on the information and documentation provided to the Medical Practitioner by or on behalf of the Insured Person.

If the Sum Insured and Cumulative Bonus (if any) is exhausted due to claims incurred and paid during the Policy Year or incurred during the Policy Year and accepted as payable, then it is agreed that a Restore Sum Insured (equal to 100% of the Sum Insured) will be automatically available for the particular Policy Year, provided that:

• The Restore Sum Insured will be enforceable only after the Sum Insured and the Cumulative Bonus have been completely exhausted in that Policy Year;
• The Restore Sum Insured can only be used for claims made by the Insured Person in respect of Benefits 1-4 (refer policy wordings).
• The Restore Sum Insured cannot be used for claims based on Maternity Expenses/Treatment;
• The Restore Sum Insured can be used for only future claims made by the Insured Person and not against any claim for an Illness (including its complications) for which a claim has been paid in the current Policy Year under Benefits 1-4(refer policy wordings).
• Only the Sum Insured (excluding Cumulative Bonus) will be considered as Restore Sum Insured;
• The Restore Sum Insured will only be applied once for the Insured Person during a Policy Year;
• If the Restore Sum Insured is not utilised in a Policy Year, it shall not be carried forward to any subsequent Policy Year.
• If the Policy is opted by You on a ‘Family Floater’ basis as specified in the Schedule, then the Restore Sum Insured will only be available in respect of claims made by those Insured Persons who were Insured Persons under the Policy before the Sum Insured and Cumulative Bonus was exhausted.

• 24 months waiting period for: Pre existing conditions, Internal Congenital Anomalies, Cataracts, Benign Prostatic Hypertrophy Hernia of all types, Deviated Nasal Septum, Hypertrophied Turbinate, Hydrocele, All types of sinuses Fistulae, haemorrhoids, fissure in ano, Dysfunctional uterine bleeding, Fibromyoma, Endometriosis, Hysterectomy, All internal or external tumors/cysts/nodules/polyps of any kind including breast lumps with exception of malignant tumor or growth. Surgery for prolapsed inter vertebral disc unless arising from Accident, Surgery of varicose veins and varicose ulcers, any types of gastric or duodenal ulcers, stones in the urinary and biliary systems, Surgery on ears and tonsils.
• 48 months waiting period for Organ transplant, Rheumatoid Arthritis, Gout, Joint replacement due to degenerative condition age related osteoarthritis, Osteoporosis , unless such joint replacement surgery is medically necessary due to injury
• First 30 days waiting period for medical expenses incurred for any illness diagnosed or diagnosable except those incurred as a result of Injury.

• Portability Form
• Proposal Form
• Previous insurance policy copies of last 4 years

Change in Sum Insured /Plan can be done at renewals only. No increase/decrease in Sum Insured/Plan is allowed during the currency of the policy. Increase in Sum Insured can be allowed up to two slabs higher, whereas increase in Plan can be allowed up to one plan higher. For age group above 60 years, increase in Plan would not be allowed. For age group up to 50 years increase in sum insured up to Rs 10Lacs (within Vital Plan) can be allowed without medical examination (in case of no claim / no health declaration). For Superior/Premiere Plan (Sum Insured above 10 lakhs), medical examination is required irrespective of age. For age group above 50 years increase in sum insured can be allowed with medical examination. Decrease in Sum Insured allowed up to one slab lower only, in case of no claim in any preceding Health Total policies.

A pre-existing disease is any condition, ailment or injury or related condition(s), for which the insured person had signs or symptoms, and /or were diagnosed, and / or received medical advice / treatment within 36/48 months prior to 1st health insurance policy issued by Us under which the insured person was covered.

Under cashless hospitalization, the insured person does not settle the hospitalization expenses at the time of discharge from hospital. The settlement is done directly by us for treatment that the insured person is eligible to receive under the terms of his/her policy. This is for your convenience. However, it is important to note here that prior approval is required from us before admission into the hospital. In some cases, you may have to pay for all or part of the treatment if it is not fully covered under the terms of the policy. However, in case of emergency hospitalization, you can obtain approval post-admission. Please note that the cashless facility is available only at our Network Hospitals.

The premium paid on a health insurance policy is eligible for deduction under Section 80D of the Income Tax Act. So save with your policy now!

A waiting period is the length of time you, the insured, will have to wait before the benefits under the health policy can be utilised.

• If claim amount is below 1 lakh- Photo Id proof & address proof
• If claim amount is above 1 lakh- Photo Id proof, address proof and a recent photograph

A deductible is a cost-sharing requirement. It states that the insurer will not be liable for a specified amount in case of indemnity policies. This is applicable for a specified number of days/hours in case of hospital cash policies which apply before any benefits are payable by the insurer. Remember that a deductible does not reduce your sum insured.

In planned hospitalization the treatment is planned well in advance. The intimation of such hospitalization and authorization from us has to be taken minimum 3 days prior to the date of hospitalization. E.g. Cataract, pace maker implantation, total knee replacement etc are examples for which the hospitalisation can be planned.The insured person should at least 3 days prior to admission to the hospital approach the network provider for hospitalization for medical treatment.

In emergency hospitalization the patient is admitted to the hospital in an emergency situation, for e.g. Severe abdominal pain, accident, heart attack etc. In such event, we should be intimated within 48 hours of admission to the hospital.

We will not be liable to pay for any claim arising out of an injury/ accident/ condition that occurred during the grace period.

You should carry the health card provided by the company with this policy, along with a valid photo identification proof (voter id card / driving license / passport / pan card / any other identity proof as approved by the company).

We may investigate claims at our own discretion to examine validity of claim. Such investigation shall be concluded within 15 days from the date of assigning the claim for investigation and not later than 6 months from the date of receipt of claim intimation. Verification carried out, if any, will be done by individuals or entities authorised by us to carry out such verification / investigation(s) and the costs for such verification / investigation shall be borne by the us.

We shall settle claims, including its rejection, within 7 (seven) working days of the receipt of the last ‘necessary’ document but not later than 30 days.

You should submit the post-hospitalization claim documents at your own expense within 15 days of completion of post-hospitalization treatment or period, whichever is earlier. We shall receive pre and post- hospitalization claim documents either along with the inpatient hospitalization papers or separately and process the same based on merit of the claim derived on the basis of documents received.