HEALTH  PLANS

LIC’s Health Plans are not plans but opportunities that knock on your door once in a lifetime. These plans are a perfect blend of insurance, investment and a lifetime of happiness!

Health Protection Plus

Introduction:

IN THIS POLICY, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER

Health is a major concern on everybody's mind these days. With sky rocketing medical expenses, the possibility of any illness leading to hospitalization or surgery is a constant source of anxiety unless the family has actively provided for funds to meet such an eventuality. Most families rarely provide for healthcare, and even if they do, it is grossly inadequate. Given this scenario, LIC has launched LIC's Health Protection Plus plan, a unique long term health insurance plan that can combine health insurance covers for the entire family (husband, wife and the children) ' Hospital Cash Benefit (HCB) and Major Surgical Benefit (MSB) along with a ULIP component (investment in the form of Units) that is specifically designed to meet Domiciliary Treatment Benefit (DTB) / Out Patient Department (OPD) expenses for the insured members.

I. Vital Information

3. Sum Assured.
The Principal Insured must first choose the respective levels of HCB for each member to be covered under the policy. The sum assured for major surgical benefits will be 200 times of the HCB you choose.

4. Other Terms of the Policy.

5. Addition of New Members. It is important for the Principal Insured (the person taking the policy) to decide which of the existing family members are to be covered and include them at the beginning (proposal stage) itself. Eligible existing family members cannot be added at a later stage. New members can however be added under the following three situations.

• The new members will be eligible for the cover only if they satisfy the conditions of minimum premium and benefits.
• New members must be included by the Principal Insured only. No new members will be allowed after the death of the principal insured.
  
  6. Increase/Decrease of Premiums. Increase or decrease of premiums is allowed during the term of the policy. Increase in premium must be in multiples of Rs.500. In case of decrease, the minimum premium conditions must be satisfied. However, increase/decrease in premiums does not affect the level of health cover and HCB and MSB benefits.

II. CONDITIONS & RESTRICTIONS

1. Premium Discontinuance and Revival. The policy will lapse if the premiums are not paid within the days of grace. The PI shall have the option to revive the policy any time within a period of two years from the due date of first unpaid premium by payment of arrears of premiums or by availing Premium Holidays. During the period of discontinuity, the charges for HCB and MSB covers will continue to be deducted (even beyond two years) from the policy fund till:

i. the policy fund has sufficient balance, or
ii.the lives covered reach the benefit ceasing age, or
iii.the maximum lifetime benefits are exhausted, or
iv.the policy is terminated due to death or any other reason, if any,
whichever is earlier.

In case the policy is not revived during the revival period and the balance in the Policy Fund is not sufficient to recover the charges i.e. if the Policy Fund exhausts, the policy shall compulsorily be terminated with a notice to the PI.
All other charges will also continue to be deducted from the Policy Fund till the fund exhausts.

2. Premium Holidays. If the policy lapses after at least 3 years’ premiums have been paid the Principal Insured has the option of either paying all the due premiums in full or avail of premium holiday by just paying the latest instalment premium without any interest. The premium holidays can be availed only as long as the policy fund has a balance of at least one annualized premium at the time of revival.

3. Surrender. No surrender will be allowed.

4. Policy Loans. No policy loan will be available under this policy.

5. Assignment. No assignment will be allowed under this policy.

6. Tax Benefit. The premium payable under this product is eligible for Section 80(D) benefit of Income Tax Act, 1961.

7. Risks borne by the Policyholder:
i)LIC’s Health Protection Plus is a Unit Linked Health Insurance product which is different from the traditional insurance products and is subject to risk factors.
ii)The premium paid in Unit Linked Life Insurance policies are subject to investment risks associated with capital markets and the NAVs of the units may go up or down based on the performance of fund and factors influencing the capital market and the insured is responsible for his/her decisions.
iii)Life Insurance Corporation of India is only the name of the Insurance Company and LIC’s Health Protection Plus is only the name of the unit linked health insurance contract and does not in any way indicate the quality of the contract, its future prospects or returns.
iv)Please know the associated risks and the applicable charges, from your Insurance agent or the Intermediary or policy document of the insurer.
v)The fund offered under this contract is the name of the fund and do not in any way indicate the quality of these plans, their future prospects and returns.
vi)All benefits under the policy are also subject to the Tax Laws and other financial enactments as they exist from time to time.

8. Cooling off period: If you are not satisfied with the 'Terms and Conditions' of the policy, you may return the policy to us within 15 days.
III. EXCLUSIONS

1. Common Exclusions in respect of HCB & MSB Benefits: No benefits are available hereunder and no payment will be made by the Corporation for any claim for Hospital Cash Benefit and Major Surgical Benefit under this Policy on account of Hospitalization directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:
a.Pre-existing condition- any medical condition or any related condition (e.g. illnesses, symptoms, treatments, pains and surgery) that have arisen at some point prior to the commencement of this coverage, irrespective of whether any medical treatment or advice was sought. Any such condition or related condition about which the PI or insured dependant know, knew or could reasonably have been assumed to have known, will be deemed to be pre-existing. The following conditions will also be deemed to be pre-existing:
i.Conditions arising between signing the application form and confirmation of acceptance by the Corporation
ii.Any Sickness, illness, complication or ailment arising out of or connected to the pre-existing illness
b.Any Sickness that has been classified as an Epidemic by the -Central or State Government.
c.Self afflicted injuries or conditions (attempted suicide), and/or the use or misuse of any drugs or alcohol.
d.Any sexually transmitted diseases or any condition directly or indirectly caused to or associated with Human Immuno Deficiency (HIV) Virus or any Syndrome or condition of a similar kind commonly referred to as AIDS.
e.War, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection military or usurped power of civil commotion or loot or pillage in connection herewith.
f.Naval or military operations(including duties of peace time) of the armed forces or air force and participation in operations requiring the use of arms or which are ordered by military authorities for combating terrorists, rebels and the like.
g.Any natural peril (including but not limited to avalanche, earthquake, volcanic eruptions or any kind of natural hazard).
h.Participation in any hazardous activity or sports including but not limited to racing, scuba diving, aerial sports, bungee jumping and mountaineering or in any criminal or illegal activities.
i.Radioactive contamination.
j.Non-allopathic methods of surgery and treatment.

2. Additional Exclusions in respect of Hospital Cash Benefit:
No benefits are available hereunder and no payment will be made by the Corporation for any claim for Hospital Cash Benefit under this Policy on account of Hospitalization directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:
a.Hospitalization due to illness within the first 180 days from the Date of Cover commencement or 90 days from the date of revival/reinstatement if revived after discontinuance of the cover.
b.Removal of any material that was implanted in a former surgery before Date of Cover commencement
c.Any diagnosis or treatment arising from or traceable to pregnancy (whether uterine or extra uterine), childbirth including caesarean section, medical termination of pregnancy and/or any treatment related to pre and post natal care of the mother or the new born.
d.Hospitalization for the sole purpose of physiotherapy or any ailment for which hospitalization is not warranted due to advancement in medical technology
e.Any treatment not performed by a Physician or any treatment of a purely experimental nature.
f.Any routine or prescribed medical check up or examination.
g.Medical Expenses relating to any hospitalization primarily for diagnostic, X-ray or laboratory examinations
h.Circumcision, cosmetic or aesthetic treatments of any description, change of gender surgery, plastic surgery (unless such plastic surgery is necessary for the treatment of Illness or Accidental Bodily Injury as a direct result of the insured event and performed with in 6 months of the same).
i.Hospitalization for donation of an organ.
j.Hospitalization for correction of birth defects or congenital anomalies
k.Dental treatment or surgery of any kind unless necessitated by Accidental Bodily Injury.
l.Convalescence, general debility, nervous or other breakdown, rest cure, congenital diseases or defect or anomaly, , sterilization or infertility (diagnosis and treatment), any sanatoriums, spa or rest cures or long term care or hospitalization undertaken as a preventive or recuperative measure.

3. Additional Exclusions in respect of Major Surgical Benefit:
No benefits are available hereunder and no payment will be made by the Corporation for any claim for Major Surgical Benefit under this Policy directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:
a.Surgeries not listed in the Surgical Benefit Annexure I
b.Surgery triggered by health related causes (and not by Accident) within the first 180 days from the commencement date or 90 days from the date of revival/reinstatement if revived after discontinuance of the cover.
c.Any Surgery for which claim has already been made and paid by the Corporation.
d.Any treatment not performed by a Physician/Surgeon.
e.Any treatment including Surgery that is performed un-conventionally under experimental conditions and purely experimental in nature.
f.Circumcision, cosmetic or aesthetic treatments of any description, change of life surgery or treatment, treatment (including surgery) for obesity, plastic surgery (unless necessary for the treatment of Illness or accidental Bodily Injury as a direct result of the insured event and performed with in 6 months of the same).
g.Surgery for donation of an organ.
h.Removal or correction or replacement of any material that was implanted in a former Surgery before Date of Cover commencement
i.Surgery for correction of birth defects or congenital anomalies.
j.Any diagnosis or treatment or surgery arising from or traceable to pregnancy (whether uterine or extra uterine).
IV. INVESTMENT OF FUNDS
The premiums allocated to purchase units will be strictly invested in a Health Protection Plus Fund (Income and Growth  Low Risk) as follows:

1. Method of Calculation of Unit price: Units will be allotted based on the Net Asset Value (NAV) on the date of allotment. There is no Bid-Offer spread. The NAV will be computed on daily basis and will be based on investment performance, Fund Management Charge and whether the fund is expanding or contracting.
a. Applicability of Net Asset Value (NAV): The premiums received up to 3 p.m. (as per IRDA guidelines) by the servicing branch of the corporation by a local cheque or by a demand draft payable at par at the place where the premium is received, the closing NAV of the day on which premium is received shall be applicable. The premiums received after such time by the servicing branch of the corporation by a local cheque or by a demand draft payable at par at the place where the premium is received, the closing NAV of the next business day shall be applicable.
b. Redeeming of Units: In respect of valid applications received for reimbursement of medical expenses, death claim, etc up to such time by the servicing branch of the Corporation closing NAV of that day shall be applicable. For the valid applications received in respect of Domiciliary Treatment Benefit, death claim etc after 3 p.m. (as per IRDA guidelines) by the servicing branch of the Corporation the closing NAV of the next business day shall be applicable.
2. Charges under the Plan:
a. Premium Allocation Charge: This is the percentage of the premium appropriated towards charges from the premium received. The balance known as allocation rate constitutes that part of the premium which is utilized to purchase (Investment) units for the policy. The allocation charges are as below:

The above allocation charges shall be applicable for all premiums including any additional premium paid in that particular policy year.
b. Health Insurance Charge: There will be two separate charges for the following benefits:
i) Hospital Cash Benefit
ii) Major Surgical Benefits.
These charges will be taken every month in respect of all the members covered by canceling appropriate number of units out of the Policy Fund.
These charges, during a policy year, will be based on the age nearer birthday, of each of the members covered, as at the Policy anniversary coinciding with or immediately preceding the due date of cancellation of units and hence may increase every year on each policy anniversary. The charges will also depend on whether the person covered is male or female and standard or sub-standard as per the underwriting decision.
If more than one member is covered under the policy then the total charges shall be based on the individual ages of all the members and the amount of cover for each such member.
In case of Hospital Cash Benefit, the charges will be applied on the Initial Daily Benefit as mentioned in the Policy Schedule.
The charges for Hospital Cash Benefit and/or Major Surgical Benefit will not be deducted once the benefit terminates.

Specimen charges for Rs. 100/- per day for HCB and Rs. 1000/- SA for MSB for standard lives are given as under:

b. Health Insurance Charge:

d. Right to revise charges-The Corporation reserves the right to revise all or any of the above charges except the Premium Allocation charge. The modification in charges will be done with prospective effect with the prior approval of IRDA.
Although the charges are reviewable, they will be subject to the following maximum limit:
Policy Administration Charge-Rs. 150/- per month during the first policy year and Rs.50/- per month thereafter, throughout the term of the policy.
Fund Management Charge-The Maximum for Fund will be 2.5% p.a. of Unit Fund
Hospital Cash Cover charges and Major Surgical Benefit charges shall not exceed by more than 200% of the current rate.

Disclaimer : For more details on risk factors , terms and conditions please read sales brochure carefully before concluding a sale .

Benefits

1. Hospital Cash Benefit (HCB). A daily benefit is payable in case the insured is hospitalized due to either accidental body injury or sickness. The quantum of benefit depends upon the level of cover opted.

*The Applicable Daily Benefit. IDB is applicable during the first year of risk cover. The daily benefit will increase @5% simple p.a. of the IDB on each policy anniversary until it hits a cap of 1.5 times the initial benefit.
IDB of the spouse cannot exceed the Principal Insured’s IDB; IDB of the children cannot exceed the spouse’s IDB.
The initial HCB must be in multiples of Rs. 50.
#Initial daily benefit that is payable in respect of stay in a non-ICU room or ward. In case the insured is required to stay in the ICU of a hospital, an enhanced rate of daily benefit is payable, which is twice the eligible daily cash benefit.
2. Major Surgical Benefit (MSB). In the event of the insured undergoing one of the major surgeries defined in the Annexure I, a lump sum benefit (regardless of the actual costs incurred) equivalent to the percentage of the sum assured mentioned against that surgery will be payable on providing proper proof of surgery to the satisfaction of the corporation.
3. Domiciliary Treatment Benefit (DTB). The Principal Insured can claim an amount equivalent to the actual expense he or she has incurred in respect of any domiciliary treatment or to meet the medical expenses incurred over and above the hospital cash/major surgical benefits in respect of either oneself or the others insured under the policy.

Note: i. A maximum of two payments will be allowed in a policy year subject to the above conditions  on production of supporting proof of treatment and bills for expenses. DTB is available only after at least 3 years premiums are paid.
ii. DTB is payable for the children covered until the health cover ceasing age.
4. Death Benefit. No death insurance cover is available under the plan. Following benefits/charges will take place on the happening of unfortunate death of principal insured (PI) and/or other insured member.

5. Waiting Period. Both HCB and MSB covers are available subject to a waiting period from the commencement of the risk cover specified hereunder  in respect of each insured member:

6. Benefit Period Limits Hospital Cash Benefit.

NOTE: i. Various HCB and MSB Benefit limits and restrictions applicable under this policy in respect of each insured shall solely and exclusively apply to that insured only and are not transferable to any other insured.
ii. HCB/MSB is payable only if the hospitalisation/surgery is performed in India.

8. Termination of HCB and MSB Benefits in respect of each insured.