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Apollo Munich Optima Plus Health Insurance plan

Apollo Munich Optima Plus Health Insurance plan Introduction

Apollo Munich Optima Plus is a unique Top-up health plan with the concept of deductible, which involves cost-sharing among the policyholder and insurance company. You have an option of converting this Top-up health plan into Full-fledged health insurance plan without any deductible, where the company will be liable to pay for all admissible expenses.

Initially, you pay a nominal premium for the top-up health plan that helps you cover higher medical expenditures. Later, when you retire, it gives you an option to choose a regular plan i.e., full-fledged health plan without any deductible. This Apollo Munich Optima Plus policy can be taken for self, spouse, dependent children and dependent parents.

Key Features and Benefits of Apollo Munich Optima Plus Plan

The double benefits of a Top-up Plan and a Full-Fledged Plan are,

Top-up plan:

Top-up plan helps you cover for higher hospitalisation expenditure.
The premium you pay is nominal under Top-up plan.
You can enjoy wide in-patient cover, after deductible.
Lifelong renewal i.e., you can renew the policy for life.

With the option of converting into a Full-fledged nil deductible plan:

There will be no waiting periods (whether it’s the initial 30 days or 2 years for specific diseases or pre-existing conditions).
Waiver of deductible is allowed under full-fledged plan and you are covered from the first rupee.
Enjoy cashless hospitalisation and wide in-patient cover under full-fledged nil deductible plan.

Deductible:

Deductible means a cost-sharing requirement among the policyholder and insurance company under a health insurance policy. It provides that the insurer will not be liable for a specified rupee amount in case of indemnity policies. And also for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are payable by the insurer. A deductible does not reduce the Sum assured.

The company is not liable for any payment unless the Medical Expenditures exceed the Deductible. Deductible shall be applicable for each and every hospitalisation except claims made for any one Illness.

Example of Deductible:

Mr. Raju has policy (Policy Period-1Jan-2010 to 31-dec-2010) with Sum assured of Rs. 5,00,000 and with a deductible of Rs. 5,00,000.

In May 2010, he is hospitalised and a claim is filed for Rs. 4,00,000. Claim is not admissible in this scenario since his deductible is Rs. 5,00,000.

In June 2010, he is hospitalised and a claim is filed for Rs. 600,000. In this scenario claim payment will be made for Rs. 1,00,000 [6,00,000-5,00,000].

Any One Illness:

Any One Illness means continuous period of illness. It includes relapse (get ill) within 45 days from the last consultation date with the hospital where treatment may have been taken.

Terms and Eligibility conditions of Apollo Munich Optima Plus Plan

Entry age:	Minimum: 91 days. (Child between 91 days to 5 years can be insured only when either parent is getting insured under Apollo Munich Optima Plus policy) Maximum: 65 years.
Policy term:	Minimum: 1 year Maximum: 2 years
Renewable till age:	Lifelong
Maximum cover ceasing age:	Nil
Sum assured:	Minimum: 3,00,000 Maximum: 15,00,000 (Apollo Munich Optima Plus policy offers coverage on individual sum assured basis only)
Waiting period for pre-existing illness:	After continuous renewal of 3 years. (Waiting period will get reduced by 1 year on every continuous renewal of your Apollo Munich Plus Health Insurance Policy.)
Grace period for renewal:	30 days
Tax benefits:	You can avail tax benefits under Section 80D of Income Tax Act. For more information regarding Tax Benefits, visit www.taxqueries.in.
Discounts:	Family Discount of 10% if two or more family members are covered under Apollo Munich Optima Plus Individual Sum Insured Plan. An additional 7.5% discount is offered on the premium if you choose a 2 year policy.
Portability:	If you are insured under another Insurer’s health insurance policy you can transfer to Apollo Munich with all your accrued benefits after due allowances for waiting periods.
Documents Required for fresh policy:	Policyholder need to fill up an ‘Application form’ with accurate medical history along with ‘address proof’. Medical examination may be required in some cases, based on the sum assured and the age of the person.
Documents Required during Renewal:	Policyholder do not have to fill the Proposal Form or ‘Application form’ again at the time of renewal in case he/she renew the policy before renewal date or within the grace period of 30 days post the renewal date. Policyholder will require to apply for a fresh policy if he/she renew the policy beyond the renewal date.

Inclusions in Apollo Munich Optima Plus Plan

Inclusions in Apollo Munich Optima Plus Plan are,

In-patient treatment: Medical expenses for Room rent, boarding expenses, Nursing, Intensive care unit, Medicines, drugs etc., will be covered
Pre-hospitalization: Medical Expenses incurred in the 60 days before the Insured Person was Hospitalised will be covered.
Post-hospitalization: Medical Expenses incurred in the 180 days after the Insured Person was discharged will be covered.
Day care procedures: Medical Expenses for a day care procedure in this Policy where the procedure or surgery is taken by the Insured Person for less than 24 hours in a Hospital will be covered for listed day care procedures.
Domiciliary Treatment: Medical Expenses incurred by an Insured Person for medical treatment taken at his home will be reimbursed.
Organ Donor: Medical Expenses will be covered for an organ donor’s treatment for the harvesting of the organ donated.
Emergency Ambulance: Company will reimburse the expenses upto Rs. 2000/- incurred on an ambulance offered by a healthcare or ambulance service provider.

Exclusions in Apollo Munich Optima Plus Plan

There are some exclusions under Apollo Munich Optima Plus Plan, they are

Deductible limit is applicable to each hospitalisation i.e., The company is not liable for any payment unless the Medical Expenditures exceed the Deductible, except in case of any one illness.
Any treatment within first 30 days of policy cover is excluded except any accidental injury.
Any Pre-existing diseases will be covered after a waiting period or continuous renewal of 3 years.
Pregnancy, dental treatment, expenses arising from HIV or AIDS and related diseases, external aids and appliances is not covered under this plan.
Specific diseases like cataract, hysterectomy, hernia, joint replacement etc., has 2 years exclusion.
Hospitalization due to war or due to nuclear, biological or chemical weapon and radiation of any kind is excluded.
Non-allopathic treatment, mental disorder, congenital diseases, cosmetic surgery or weight control treatments are excluded.
Abuse of intoxicant substance like drugs and alcohol is excluded.

For detailed information refer the Form and Brochure attached below.

Conversion into a full-fledged nil deductible Health Insurance plan

Apollo Munich Optima Plus gives you an option to choose a full-fledged 5 lakh Indemnity Health insurance plan provided that you,

Initially, enroll with the company under this Apollo Munich Optima Plus policy before the age of 50 years.
And have renewed with the company continuously and without interruption.
At the time of renewal, opt for conversion between 58 – 60 years of age.

Portability for waivers of waiting periods will be offered, to the extent of benefits covered in the Apollo Munich Optima Plus policy.

Annual Premium Rates:

Sum Insured	5 Lacs	5 Lacs	5 Lacs	5 Lacs	5 Lacs
Deductible	1 Lac	2 Lacs	3 Lacs	4 Lacs	5 Lacs
91 Days-35 Years	1,999	1,049	899	799	699
36-45 Years	2,750	1,500	1,400	1,300	1,200
46-60 Years	4,813	2,925	2,170	2,015	1,860
61-75 Years	10,106	5,704	3,472	2,519	2,325
>75 Years	24,053	14,254	9,090	6,894	6,640

The premium for the Optimum Plus policy will remain the same for the policy period as mentioned in the policy schedule.
Premium at renewal may change due to changes in the applicable Tax rate or a change in your age.

For example:

Proposed Insured of Age 33 years opting for 2 year Policy with Sum assured of Rs. 5 Lakhs and Deductible of Rs. 2 Lakhs.

Calculation – 1,049 x 2 x (100 – 7.5)% = Rs. 1940.65 + taxes.

Proposed Insured of Age 35 years opting for 2 year Policy with Sum assured of Rs. 5 Lakhs and Deductible Rs. 2 Lakhs.

Calculation – (1,049+1,500) x (100 – 7.5)% = Rs. 2357.82 + taxes

Claim procedure under Apollo Munich Optima Plus Plan

Claim Procedure for Hospitalization related benefits,

Intimation and Assistance:

For intimation of claim, contact the company at least 48 hours prior to an event which might give rise to a claim. For any emergency situations, contact them 24 hours of the event.
You can contact them through, Toll Free: 1800-102- 0333, Fax: 1800- 425- 4077 and get detailed information.
Use the Claim Intimation Form for intimation of a claim.

Claim Procedure for Reimbursement of Medical Expenses:

For Reimbursement of Medical Expenses, you should send the duly signed claim form and all the documents such as Hospital Main Bill, Pharmacy Bill, ECG, Hospital Bill Payment Receipt, Doctor’s Prescription, etc., to the company within 15 days of the completion of the treatment.
If there is any deficiency in the documents or information submitted by you, company will send the deficiency letter within 7 days of receipt of the claim documents.
On receipt of the complete set of claim documents, company will make the payment for the admissible amount, along with a settlement statement within 30 days.
Payment will be made in the name of the proposer, for items covered under your policy.

Claim Procedure to avail Cashless facility:

For any emergency hospitalisation, company must be informed within 24 hours after the treatment or Hospitalisation, then it will provide cashless service by making payment to the extent of their liability directly to the Network Hospital.
For any planned hospitalization, company must be given notice within at least 48 hours before the planned treatment or Hospitalisation, then it will provide cashless service by making payment to the extent of their liability directly to the Network Hospital.
If in case there is any deficiency in the documents or information sent, the same shall be communicated to the hospital within 6 hours of receipt of documents.
Insured person is entitled for cashless only in their network hospitals.
In case the treatment is not covered under Apollo Munich Optima Plus policy a rejection letter would be sent to the provider within 6 hours.

Frequently asked questions (FAQ) of Apollo Munich Optima Plus Plan

What is difference between Top-up plan and full-fledged nil deductible plan?

Apollo Munich Optima Plus is India’s only Top-up health plan with an option of converting into a full-fledged nil deductible health plan. There is a deductible applied, when it operates as a Top-up plan. Where as, all deductible are waived when it converts into a full-fledged plan.

What about the cancellation of Apollo Munich Optima Plus policy?

The policy will be cancelled by the company on grounds of misrepresentation, noncooperation, or any fraud by Insured Person. The Company gives 30 days notice without refund of premium.
Policyholder is allowed to terminate the policy at anytime by giving a written notice to the company.
In case no claim has been made under Apollo Munich Optima plus policy, percentage of premium will be refunded.

What are the requirements to take Apollo Munich Optima Plus policy?

To take Apollo Munich Optima Plus policy, completed proposal form is required along with the address proof.

What is meant by Pre-existing Condition?

Pre-existing Condition means any condition for which Insured Person had symptoms, and/or were diagnosed, and/or received medical treatment, within 48 months prior to the commencement of his first being covered under an Apollo Munich Optima Plus Policy with the company.