Super Topup Insurance

What is a Super Topup policy?

A 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.Raju submitted 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?

One can argue that instead of opting for a top up, a higher cover can be obtained from the insurance provider. That can be done, but a higher cover would also increase the premium amount.

Since top up plans have a high deductible, insurers consider them less risky and they are made available at relatively low rates. In fact, the higher the deductible, the cheaper the plan. An individual can purchase a top up plan even if does not have a regular health insurance policy.

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.

Because of advancement in medical technology, in certain surgeries, the inpatient Hospitalisation can be less than 24 hours. Those are called day care procedures. Insurer keeps identifying those procedures and settles 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.

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.

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, i. 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. We have accepted an inpatient Hospitalisation claim for the insured member under Medical expenses section

The Pre-Existing Diseases are not covered under the policy for certain months as mentioned in the policy. This period is called as waiting period and it starts from the date of inception of first policy with the insurer. Under this period the policy should have a continuous coverage and should not have any break.

It is necessary and in interest of the Policy holder to declare all the known pre-existing diseases one is already having. The insurer may reject the claim if they find that the policy holder 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.

A loading on your premium amount may be applicable as per nature of such preexisting disease. Not all pre-existing diseases will attract loading. Applicability & percentage of loading will be ascertained by medical underwriter. If a loading is applicable for your health insurance proposal, we will send you a counter offer. Only if you accept this offer and pay additional premium, we will issue your policy. If you do not accept such counter offer within 15 days, policy will not be issued and premium will be refunded after adjusting for expenses incurred by us on your pre-policy medical check-up.

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 first issuance of this policy, same loading will apply at the time of renewal as well.

No, pre-policy medical tests is not required at the time of renewal for same coverage. However, if there is a change like 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 medical underwriter for assessment of such enhancement/change.

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.

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.

  1. Any amount falling under the deductible as opted and mentioned in the policy.
  2. Insurer shall not indemnify you for any period of hospitalisation of less than 24 hrs, except for Day Care Procedures.
  3. New 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. War, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, commotion, unrest, rebellion, revolution, insurrection, military or usurped power or confiscation or nationalisation or requisition of or damage by or under the order of any government or public local authority.
  6. Circumcision unless required for the treatment of Illness or Accidental bodily injury, cosmetic or aesthetic treatments of any description, treatment or surgery for change of life/gender.
  7. Any form of plastic surgery unless necessary for the treatment of cancer, burns or accidental Bodily Injury
  8. External medical equipment of any kind used at home as post hospitalisation care
  9. Convalescence, general debility, rest cure, congenital external diseases or defects or anomalies, genetic disorders, stem cell implantation or surgery, or growth hormone therapy.
  10. Intentional self-injury
  11. Ailments requiring treatment due to use or abuse of any substance, drug or alcohol and treatment for deaddiction
  12. Any condition directly or indirectly caused by or associated with Human Immunodeficiency Virus or Variant/ mutant viruses and or any syndrome or condition of a similar kind commonly referred to as AIDS
  13. Outpatient expenses unless falling under pre and post hospitalisation.
  14. 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, sub fertility, Infertility, sterility, erectile dysfunction, impotence, assisted conception operation or sterilization procedure.
  15. Vitamins, tonics, nutritional supplements unless forming part of the treatment.
  16. Experimental, unproven or non-standard treatment
  17. Weight management services and treatment related to weight reduction programmes including treatment of obesity & treatment for arising direct or indirect complications of Obesity.
  18. Treatment for any mental illness or psychiatric illness, Parkinson’s disease.
  19. All non-medical Items as provided in Policy Wordings.
  20. Any treatment received outside India.
  21. Treatment for any other system other than modern medicine (also known as Allopathy)
  22. Venereal disease or any sexually transmitted disease or sickness.

Cashless treatment is only available at a Network Hospital.

To avail cashless treatment, following procedure must be followed by You.

Prior to taking treatment and/or incurring Medical Expenses at a Network Hospital, Insured must call Insurer and request pre- authorization by way of the written form.

Insurer may provide waiver of above condition in case of emergency hospitalisation arising out of accidental bodily injury.

In the 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 Your 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 have 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, insurer will not be required to directly pay for the Medical Expenses above the Aggregate deductible in the Network Hospital that We are 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 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.

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 cashless facility, then following procedure must be followed

  1. You or someone claiming on Your behalf must inform insurer in writing immediately within 48 hours of hospitalisation in case of emergency hospitalisation and 48 hours prior to hospitalisation in case of planned hospitalisation
  2. You must immediately consult a Doctor and follow the advice and treatment that he recommends.
  3. You must take steps or measure to minimize the quantum of any claim that may be made under this Policy.
  4. You or someone claiming on Your behalf must promptly and in any event within 30 days of discharge from a Hospital give insurer the documentation.
  5. In the event of the death of the insured person, someone claiming on his behalf must inform insurer in writing immediately and send insurer a copy of the post mortem report (if any) within 30 days.
  6. n 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 we 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.

Documents to be submitted for Claims

  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. Original Hospital Bill giving detailed break up of all expense heads mentioned in the bill. Clear break ups have to be mentioned for OT Charges, Doctor’s Consultation and Visit Charges, OT Consumables, Transfusions, Room Rent, etc.
  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 Operation, 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, we may call for any additional document(s) in addition to the documents listed above.
  10. Aadhar card & PAN card Copies

The premium paid for health insurance policies qualifies for deduction under Section 80D of the Income Tax Act. You are eligible for a deduction of Rs. 25000 for premium paid on the health for yourself, your spouse and children. Also, if you pay health insurance premium for your parents (Senior Citizen), you will be entitled to additional deduction of Rs. 30000/- Tax benefit is applicable if premium is paid by any mode of payment, other than cash

Your policy premium can change in case of following conditions: 1. If age band changes: If age band changes, the premium will be as per the age band applicable 2. If Tax/ cess is changed: If government changes/ adds any tax or cess, the premium will change accordingly 3. Product pricing revision: If the product pricing is revised, as per approval from IRDAI, premiums would change