Add Member Detailsfor super topup policy
Why do you need a Super Top-up policy Anyway?
The average medical cover provided by an employer is generally in the range of Rs 3 Lakh to Rs 5 Lakh, however considering the medical expenses in current medical settings, do you think that the coverage by the employer is enough? No! What choices are you left with-paying the medical expenses out of your own pocket and that ends up putting an extra unnecessary burden on your shoulders! Okay, we understand that this isn’t a happy picture, right?
what is the solution?
An additional health cover to your existing health insurance will bring in lots of benefits, yes, that’s what we call “The Super Top-up insurance!
The Super Top Up Insurance as a fresh policy or as an added cover to your existing health insurance enhances your health cover to provide you with a larger coverage at a much affordable premium. Let’s dig deeper and understand how super top-up works, shall we!
How does Super Top-up Insurance work ?Super Top-up Insurance strengthens the existing plan to give you a higher sum insured and a much wider cover to meet your medical expenses. When your existing health cover gets exhausted, super top-up has got your back, it offers you protection and secures your financial well-being during medical emergencies. It offers a higher sum insured against aggregate deductible at an affordable premium.
Case StudyA health top-up plan provides the financial backup you needed after your base plan is exhausted.
Mr. Raju had a major Surgery for which the medical expenses were Rs 9 lakhs. His insurance policy provided by his company had a threshold limit of Rs 3 lakhs. When his boss asked how he would manage the rest of the expenses, Mr. Raju said that he has a Super top-up plan.
A regular health insurance policy has a sum insured limit, beyond which it does not cover any expenses. This is when a Super top-up policy is useful, it becomes effective soon as the sum assured from a health plan is exhausted. Therefore, Ms.Raju can claim the balance amount of Rs 6 lakhs from his top-up health cover. So essentially, he has a top up plan with a deductible of Rs 3 lakhs.
Can you give one example of this claim?Let’s understand how super top up works as an added cover for extra benefits
Lets say you have taken two policies
1. A Normal Health policy of 3 lacs and (it could be your corporate policy or you may choose to cover up to 3 lacs from your pocket. )
2. Super top up policy of 10 lacs with 3 lacs deductible.
Case 1: If the claim is of 9 lacs
Policy 1: will pay 3 lacs which is equal to its sum insured. If you don’t have a base policy or corporate policy, then this amount will be paid from your pocket.
Policy 2: This policy will pay above 3 lacs (which is deductible). That means 6 lacs (9-3=6) will be paid from this policy.
You will be still having a balance sum insured of 4 lacs (10 lacs – 6 lacs = 4 lacs) in the super top up policy which can be utilised in any future claims.
What is difference between Super top up and Top up ?
A super top up comes to the rescue when a single claim does not cross the deductible limit of top up policy, but multiple claims do. Thus, if Mr.Rajusubmitted three different claims of Rs 3 lakhs, Rs 3 lakhs and Rs.3 lacs respectively, the top up plan would be useless since none of them exceed Rs 3 lakhs individually. Thus once should always choose Super top up instead of Top up.
I don’t have any Health Insurance policy. Which one I should take first? Normal Health policy or Super top up policy?This way, you are first securing yourself from the major loss which has a possibility of evading all your savings or may also put you in debts. The premium is also very less so it will not affect your pocket. Also, the cost of Health care is increasing every year, so by taking the super top up you have taken care of Inflation in the cost of Health care.
If your budget is still permitting, then go for base policy.
If I already have Base policy provided by my employer, Can I take the Super top up outside?
Most organizations offer a medical cover to their employees. However, each individual has different requirements, and someone might feel that the organization’s insurance policy is insufficient for his/ her requirements. In that case he/she might opt for a top up or a super top up plan.
So, if the health insurance policy offered by the employer has Rs 6 lakh sum assured and an employee feels that it will not meet his/her requirements, he/she can purchase a top up with Rs 6 lakhs as deductible.
With medical expenses and hospital charges on the rise, it makes sense to invest in a top up or super top up policy, in addition to a base plan. Also, premiums paid for either are eligible for income tax deduction under Section 80 D.
Whether I should increase the cover in the base policy or should I take a Super top up policy ?Instead of going for a top-up policy, one can increase the cover in the base policy, however, there is a catch- a higher cover would also increase the premium amount.
Investing in a top-up cover is quite simple as a policyholder can get it from any company and not necessarily from the existing insurer
What does it Cover ?This covers the inpatient hospitalization expenses incurred due to an illness or accident, for a minimum of 24 hours. It pays for medical expenses including room rent, nursing, medical practitioner, boarding expenses, ICU, Operation theatre, medicines and other related requirements
What if my hospitalisation is less than 24 hours ?
With the advancement in medical technology, in certain surgeries, the inpatient Hospitalisation can be of less than 24 hours. Those are called day care procedures. Insurer keeps identifying those procedures and settles the claim and waives of that 24 hours minimum hospitalisation clause. It is advisable to refer cases to the Insurer and take prior approval before hospitalisation.
What about the outpatient expenses incurred Pre and Post Hospitalization ?
Covers medical expenses that occur during the number of days immediately before and after hospitalization, as specified under the Health Insurance Policy for family or individual. This coverage provided is towards consultations, tests and medications.
Does it also cover Expenses incurred for Organ Donor ?
The policy will pay for Medical treatment of the organ donor for harvesting the organ i.e. including surgery to remove organs from a donor 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 (AMENDMENT) BILL, 2011 ii. The organ donated is for the use of the Insured Person, and iii. The insurer has accepted an inpatient Hospitalisation claim for the insured member under Medical expenses section.
What is pre-existing Waiting period ?The Pre-Existing Diseases are not covered under the policy for a certain period (known as a waiting period) as mentioned in the policy. Waiting period starts from the date of inception of first policy with the insurer. Under this period the policy should have continuous coverage and should not have any break.
It is necessary and in the interest of the Policyholder to declare all the known pre-existing diseases one is already having. The insurer may reject the claim if they find that the policyholder has intentionally not declared the existing disease at the time of first taking the policy even when the claim is made after the Pre-existing waiting period.
I have pre-existing disease. Do I need to pay an extra premium?
A loading on your premium amount may be applicable as per nature of such pre-existing disease. Not all pre-existing diseases will attract loading. Applicability & percentage of loading will be ascertained by a medical underwriter. If loading is applicable for your health insurance proposal, the insurer will send you a counter offer. Only if you accept this offer and pay an additional premium, the insurer will issue the policy. If you do not accept such counter offer within 15 days, the policy will not be issued, and premium will be refunded after adjusting for expenses incurred by us on your pre-policy medical check-up.
Is there any loading on the premium at the time of renewal?There is no claim-based loading. However, if there was a loading based on customer’s health condition on policy premium at the time of the first issuance of this policy, the same loading will be applicable at the time of renewal as well.
Do I have to undergo pre-policy medical tests at the time of renewal as well?No, pre-policy medical tests are not required at the time of renewal for the same coverage. However, if there is a change- you want to enhance your sum insured or if you want to add new member or change in plan or optional cover is to be added, medical examinations may be required by the medical underwriter for assessment of such enhancement/change.
What is 30 days waiting period?Any disease contracted, and /or medical expenses incurred in respect of any disease /illness by the insured during the first 30 days from the commencement of the policy, except for accidental injuries.
What is 1 year / 2 year /3-year waiting period?For certain standard ailments like Cataract, Hernia, Hydrocele, Fistulae, Hysterectomy and as specified in the policy a waiting period of 1/2/3 year is applicable as specified in the policy.
What is not covered under the policy?1. Any amount falling under the deductible as opted and mentioned in the policy
2. The insurer shall not indemnify you for any period of hospitalisation of fewer than 24 hrs, except for Day Care Procedures
3. Newly born baby expenses
4. Dental treatment or surgery of any kind unless requiring hospitalisation and
as a result of accidental Bodily Injury to natural teeth
5. Cosmetic or aesthetic treatments/gender change treatment or surgery
6. Circumcision unless required for a testament of illness or accidental bodily injury.
7. Civil unrest (war, rebellion, invasion), military/confiscation/nationalisation or requisition of or damage by or under the government/public local authority
8. Any form of plastic surgery unless necessary for the treatment of cancer, burns or accidental Bodily Injury
9. General debility, Genetic disorders, growth hormone therapy, congenital external diseases/defects/anomalies, stem cell implantation, convalescence
10. External medical equipment of any kind used at home as post hospitalisation care
11. Intentional self-injury
12. Conditions associated with HIV (Human immunodeficiency virus) or condition of a similar kind
13. Ailments requiring treatment due to use or abuse of any substance, drug or alcohol and treatment for deaddiction
14. Outpatient expenses unless falling under pre and post hospitalisation
15. Vaccination or inoculation unless forming a part of post-bite treatment or if medically necessary and forming a part of treatment recommended by the treating doctor. 15. Any fertility, subfertility, Infertility, sterility, erectile dysfunction, impotence, assisted conception operation or sterilization procedure
16. Vitamins, tonics, nutritional supplements unless forming part of the treatment
17. Experimental, unproven or non-standard treatment
18. Weight management services and treatment related to weight reduction programmes including treatment of obesity & treatment for arising direct or indirect complications of Obesity
19. Treatment for any mental illness or psychiatric illness, Parkinson’s disease.
20. All non-medical Items as provided in Policy Wordings
21. Any treatment received outside India
22. Treatment for any other system other than modern medicine (also known as Allopathy)
23. Venereal disease or any sexually transmitted disease or sickness
What would be the process to avail a claim in a cashless network?To avail cashless treatment, the following procedure must be followed:
• Need to fill a form – Pre-authorization request prior to undergoing/incurring medical expenses at a network hospital
• An insurer may provide a waiver of the above condition in case of emergency hospitalisation arising out of accidental bodily injury
• In an event of Planned Hospitalization- Insured member should intimate such admission at least 72 hours prior to the planned admission
• Emergency Hospitalization- Insured member or his representative should intimate such admission within 24 hours of such admission
• After considering the request and after obtaining any further information or documentation insurer have sought, they may if satisfied send You or the Network Hospital, a pre-authorization letter. The pre-authorization letter, the ID card issued to You along with this Policy and any other information or documentation that insurer has specified must be produced to the Network Hospital identified in the pre-authorization letter at the time of Your admission to the same
• If the procedure above is followed, the insurer will not be required to directly pay for the Medical Expenses above the Aggregate deductible in the Network Hospital that Insurer is liable to indemnify under the policy and the original bills and evidence of treatment in respect of the same shall be left with the Network Hospital. Preauthorization does not guarantee that all the costs and expenses will be covered. Insurer reserve the right to review each claim for Medical Expenses and accordingly coverage will be determined according to the terms and conditions of this Policy. You shall, in any event, be required to settle all other expenses directly
What would be the process to avail a claim in Reimbursement?If pre-authorization under Cashless Claim Procedure mentioned above is denied by Insurer or if treatment is taken in a Hospital other than a Network Hospital or if You do not wish to avail the cashless facility, the following procedure must be followed:
i. The claimant must inform the insurer within 48 hours (in case of emergency) or 48 hours prior to hospitalization (in case of planned hospitalization)
ii. Must immediately consult a Doctor and follow the advice and treatment that he/she recommends.
iii. Must take steps or measure to minimize the quantum of any claim that may be made under this Policy.
iv. The claimant or someone claiming on the behalf of the claimant must promptly and in any event within 30 days of discharge from a Hospital give the insurer the documentation.
v. In the event of the demise of the insured person, someone claiming on his/her behalf must inform insurer in writing immediately and send insurer a copy of the post-mortem report (if any) within 30 days.
vi. In the event of a claim, the original documents to be submitted & after the completion of the claims assessment process the original documents may be returned if requested by the insured in writing, however, the insurer will retain the Xerox copies of the claim documents.*Note: Waiver of conditions (i), (iv) and (v) may be considered where it is proved to the satisfaction of the Company that under the circumstances in which the insured was placed it was not possible from him or any other person to give notice or file claim within the prescribed time limit.
What are the documents to be submitted in Reimbursement claim?1. First Consultation letter from the Doctor
2. Duly completed claim form and NEFT Form signed by the Claimant
3. Original Hospital Discharge Card
4. Hospital bill with the detailed breakup of all the expenses
5. Original Money Receipt, duly signed with a Revenue Stamp
6. All original Laboratory and Diagnostic Test Reports. E.g. X-Ray, E.C.G, USG, MRI Scan, Hemogram etc.
7. In case of a Cataract intervention, IOL Sticker will have to be enclosed
8. Claim settlement letter from any other insurer (if any) in case of partial settlement
9. In cases of suspected fraud/misrepresentation, the insurer may call for any additional document(s) in addition to the documents listed above
10. Aadhar card & PAN card Copies
For how long the policy can be renewed?Good news: Lifelong.
Can I avail Income tax benefit under Section 80D for the premium paid?
Yes, you are eligible for a deduction of INR 25000 for a premium paid on the health for yourself, for your spouse and children. Also, if you pay the health insurance premium for your parents (Senior Citizen), you will be entitled to an additional deduction of Rs. 30000/- Tax benefit is applicable if the premium is paid by any mode of payment, other than cash
Will my premium increase at the time of renewal?Your policy premium can change in case of following conditions:
• If age band changes: If age band changes, the premium will be as per the age band applicable
• If Tax/ cess is changed: If government changes/ adds any tax or cess, the premium will change accordingly
• Product pricing revision: If the product pricing is revised, as per approval from IRDAI, premiums would change
|Policy Name||Bajaj Extra Care Plus||Liberty Supera||United Supertopup||HDFC ERGO Medisure||Star Health Super Surplus Gold||ORIENTAL SUPERTOP-UP||New India Assurance|
|Minimum Entry Age||18||18||18||18||18||18||18|
|Maximum Entry Age||80||65||65||65||65||70||65|
|Pre Existing Waiting period
|Room Rent Limits
||Standard Private Room||Standard Private Room||Standard Private Room||Standard Private Room||Standard Private Room||Standard Private Room||For Normal : Rs. 5000 Per Day For Rs. 5,00,000 Threshold And Rs. 8000 Per Day For Rs. 8,00,000 Threshold. For ICU : Rs. 10000 Per Day For Rs. 5,00,000 Threshold And Rs. 16000 Per Day For Rs. 8,00,000 Threshold|
||Not Applicable||Not Applicable||Not Applicable||Not Applicable
||10% If Age Is More Than 60 Years||Not Applicable||Not Applicable|
|Pre And Post Hospitalisation
||60 & 90 Days Respectively||30 & 60 For Option 1 And 60 & 90 For Option2||30 & 60 Days||30 & 60 Days||60 & 90 Days Respectively||30 & 60 Days||30 & 60 Days|
|Other Advantage||Maternity Related Complications Covered With Waiting Period Of 12 Months||Option Of Taking World Wide Cover||No Increase In Premium After 60 Years Of Age||–||–||–|
||30 Days. One Year Waiting Period.
||30days. Two Year Waiting Period.
||Not Applicable||30days. Two Year Waiting Period.
||30 Days. One Year Waiting Period.
||30 Days And Two Years.
|Pre Policy Check Up||Required Above 55 Years
||Not Applicable For Clear Proposals||Above 45 Years
||Above 55 Years
||Not Applicable For Clear Proposals||Above 55 Years||Above 50 Years
|Free Medical Check Up||Once In Three Years
||Not Applicable||Not Applicable||Not Applicable||Not Applicable||Not Applicable||Not Applicable|
|Cumulative Bonus||Not Applicable||10% Every Year
||Not Applicable||Not Applicable||Not Applicable||Not Applicable|
|Optional Covers||Air Ambulance||Reload
||Not Applicable||Not Applicable||Not Applicable||Not Applicable||Not Applicable|
|Optional Covers||Not Applicable||Worldwide Cover
||Not Applicable||Not Applicable||Not Applicable||Not Applicable||Not Applicable|
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At Ethika, we understand that Insurance Broking is about ensuring the best interest of our customers and establishing trust. Our team has diverse experience and strong expertise which enables us to understand your business needs and your risks well. Our experts are highly innovative and they deploy the latest technology tools to bring Speed, Effectiveness and Utmost Responsiveness to your doorstep.
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Mumbai, Maharashtra 400059
+ 91 22 2640 8431
Ethika Insurance Broking Pvt. Ltd. IRDAI Certificate No: 574, Date of License: 8th Aug 2016, License valid till 7th Aug 2019,
Registered Address: 517, B Block, Vijaya Raghwa Township, Nallagandla Bypass Road, Lingampally. 500019
Principal Officer: Susheel Agarwal, Contact Details of Principal Officer: firstname.lastname@example.org +91 8498094600,
Directors: Susheel Agarwal and Suresh Agarwal, Category of License: Direct (Life and General).
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