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OPD Coverage Health Insurance Plans
Last Updated On- 05, April 2012
(1) Who offers OPD Coverage as a part of Health Insurance Plan   (2) Policy Wording/ Proposal Form/ Brochure
(3) Product details of Various Companies for OPD Coverage Insurance Policy
General/Health Insurance Companies Products
3- ApolloMunich Maxima Health Insurance Policy
Maxima Health Prospectus Suitability
- This policy covers persons in the age group 91 days onwards. The maximum entry age is 65 years.
- There is no maximum cover ceasing age in this policy.
- The policy will be issued for a period of 1 year.
- 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.
- The family includes spouse, dependent children and dependent parents.
- The premium under floater coverage will be charged on the age of the oldest insured member.
Salient Features & Benefits Outpatient Module
Outpatient Module
We will issue Entitlement Certificate to the Insured Person for availing Outpatient benefits within the Network service provider. Reimbursement of expenses for OPD consultation, Diagnostic Tests, Pharmacy, Out-patient Dental Treatment, and Spectacles, Contact Lenses would be done in cases where the member visits a nonnetwork provider. For Annual Health Check-Up benefit, no reimbursement is allowed.
- Outpatient Consultations- Outpatient consultations by a general Medical Practitioner(s) or a specialist Medical Practitioner(s). - Diagnostic Tests - Outpatient diagnostic tests taken by the Insured Person from a diagnostic centre (not necessarily to be prescribed by Network Medical Practitioner).
- Pharmacy - Medicines purchased by the Insured Person from a pharmacy, provided that such medicines have been prescribed in writing by a Medical Practitioner (not necessarily to be Network Medical Practitioner).
- Outpatient Dental Treatment - Any necessary dental treatment taken by an Insured Person from a dentist provided that We will not pay for any dental treatment that comprises cosmetic treatment.
- Spectacles, Contact lenses - Either one pair of spectacles or contact lenses, provided that these have been prescribed for the Insured Person by a Eye specialist Medical Practitioner(s).
- Annual Health Check Up within specified Network - A health check-up for the Insured Person within Network .[This benefit is not available to the Insured Persons above the age of 45 years in the first Policy Year and to the Insured Persons below 18 years of age.]
Outpatient benefit Network is available in following cities (Chennai, Delhi, Mumbai, Hyderabad, Bengaluru, Ahmedabad, Kolkata).
If an Entitlement Certificate has been used and results in treatment to which Inpatient Module responds, then We would be refunding the Entitlement Certificate used for pre-hospitalisation by issuing fresh Entitlement Certificate.
Inpatient Module :
- In-patient Treatment– It covers hospitalisation expenses due to an illness or accident. We will pay for 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, Cost of prosthetic & other devices or equipments if implanted internally during a Surgical Procedure.
- 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.
- Post-Hospitalisation- The Medical Expenses incurred in 60 days immediately after the Insured Person was discharged post-hospitalisation. It can be increased to 90 days if claim is intimated 5 days before hospitalisation.
- Day Care procedures– The Medical Expenses for 140 enlisted Day care procedures which do not require 24 hours hospitalisation due to technological advancement.
- Domiciliary Treatment- The Medical Expenses incurred by an Insured Person for availing medical treatment at his/her home which would otherwise have required Hospitalisation.
- Organ Donor- The Medical Expenses for an organ donor’s treatment for the harvesting of the organ.
- Emergency Ambulance– Expenses upto Rs. 2,000 per hospitalisation for utilizing ambulance service for transporting Insured Person to Hospital in case of an emergency or from one hospital to another if medical services required are not available.
- Maternity Expenses– Medical Expenses for maternity including pre-natal and post-natal expenses after a waiting period of 4 years.
- Newborn baby– Optional coverage for newborn from birth (day 1 - 90) for In-patient Treatment benefit, subject to acceptance of proposal and premium payment in full.
- Daily Cash for choosing shared accommodation- Daily cash amount per day if the Insured Person is hospitalised in shared accommodation in a Network Hospital and hospitalisation exceeds 48 hrs.
- Daily Cash for accompanying an Insured Child- Daily cash amount for 1 accompanying adult if insured child under 12 years 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 the Critical Illness is diagnosed during the policy period and the Insured Person survives 30 days after the diagnosis. This benefit can be opted on payment of additional premium. This benefit if opted is applicable to all family members on Individual Sum Insured Basis equivalent to Rs 300,000/-. This benefit will not be renewed beyond 70 years of age.
Sum Insured: 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/-.
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