Group Insurance October 6, 2020

SBI General Insurance Company Limited offers you a coverage plan that offers you and your family members the financial protection against future health risks. This is Group Health Insurance SBI Plan, which is available for 1 year. But with mutual consent with the insurer, you can renew this policy every year. Read this page and know more about the policy coverage and exclusions.

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Key Features of the Group Health Insurance SBI Plan

There are some of the key benefits of this health insurance plan that makes it the user’s first choice, have a detailed look at them.

No Medical Check-up

The company won’t require a medical check-up of the insured if he/she doesn’t have any medical history. And the age of the insured remains up to 65 years or below.

Multiple Coverages

This health insurance plan not only covers the insured individual but also his/her family members under the Family Floater plan of Group Health Insurance – SBI.

Tax Exemption

Under Section 80D of the Income Tax Act, you can claim deductions on health insurance premium payments.

Wide Coverage

You can get coverage of INR 1 to 5 lakh with the Group Health Insurance – SBI plan.

Group Health Insurance SBI Plan Coverage

The company will pay the expenses incurred by or on behalf of the insured person under the following circumstances, but it does not exceed the policy Sum Assured and this may be subject to deduction of any deductible as reflected in the policy schedule. Check out the pointers and find the list of expenses covered in this policy.

  1. Room, Board & Nursing Charges from the hospital – The company will pay up to 1% of the Sum Insured that may be subject to a maximum of INR 1500 for Normal Room, per day. If the insured is admitted to an Intensive Care Unit (ICU), the company will pay up to 2% of the Sum Insured, per day, which could be subject to a maximum of INR 2500. In case you choose a higher room category than your eligibility, the company will pay the expenses under specific acceptance by the insurer or administrator. In such a case, the company isn’t liable to recover any expenses towards proportionate deductions other than the defined ‘associate medical expenses’.
  2. Medical Practitioner and Specialists Fees ( Plus Teleconsultation)
  3. Anesthesia, Blood, Oxygen, Operation Theatre(OT)  charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials, X-ray, Dialysis, Chemotherapy, Radiotherapy, Pacemaker cost, prosthesis or internal implants, and any medical expenses incurred and part of the operation.
  4. The company will pay the expenses incurred 30 days before the date of hospitalization
  5. The company will pay the expenses incurred 60 days after the date of discharge from the hospital or Domiciliary Hospitalization
  6. The insurer will also pay for the Day Care expenses incurred on advanced technological surgeries and procedures that require less than 24 hours of hospitalization.  As per the company norms, you need to submit an attached list, and subject to the condition and after getting approval from the administrator or insurer, such Day Care Procedures or Expenses will become payable.
  7. If the insured is undergoing treatment in a hospital other than the list of network hospitals empanelled by the company or administrator, the insured person has to bear 10% of the eligible admissible claim as per the terms of the insurance plan or shall bear a 1% of the eligible admissible claim as stipulated in the schedule for the said purpose.
  8. The company covers reasonable and customary charges towards Domiciliary Hospitalisation exceeding 3 days (subject to 20% of the Basic Sum Insured or a maximum of up to INR.20,000.
  9. Expenses incurred for Inpatient treatment due to any condition caused by or associated with Human Immunodeficiency Virus (HIV) or variant/mutant viruses of any syndrome or condition of a similar kind commonly referred to as AIDS. For this, the company will pay up to the Sum Insured or as per the specified schedule of the policy, except for the conditions that are permanently excluded from it.
  10. Expenses incurred for the inpatient treatment for any mental illness or psychiatric or psychological ailment or condition. In such a case, the company pays up to the Sum Insured or as it is specified on the policy schedule.
  11. Genetic Disorders or Diseases are covered up to the Sum Insured or as it is specified in the policy schedule.
  12. Internal Congenital Diseases are covered up to the Sum Insured or as it is specified in the policy schedule.
  13. Wherever medically indicated treatments are performed either as in-patient or as part of daycare treatment in a hospital, the company will cover up to the Sum Insured or as it is specified in the policy schedule. The following procedures are included in it.
    1. Uterine Artery Embolization and HIFU (High-intensity Focused Ultrasound)
    2. Balloon Sinuplasty
    3. Deep Brain Stimulation
    4. Oral Chemotherapy
    5. Immunotherapy – Monoclonal Antibody to be given as an injection
    6. IntraVitreal Injections
    7. Robotic Surgery
    8. Stereotactic Radiosurgery
    9. Bronchial Thermoplasty
    10. Vaporisation of the Prostate ( Green Laser Treatment or Holmium Laser Treatment)
    11. IONM – (Intra Operative Neuro Monitoring)
    12. Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered

Exclusions from Group Health Insurance SBI

If you are diagnosed with any of the below-mentioned diseases or injuries, the company will not pay for any expenses. Have a look at them.

  1. Treatment related to your pre-existing disease and its direct complications is also excluded until the policy completes 48 months of continuous coverage after the date of inception of the first policy with the insurer.
  2. In case you enhance the sum insured, the exclusion shall apply afresh to the extent of your increased sum insured.
  3. If you are continuously covered without any break, the waiting period for the pre-existing disease would be reduced to the extent of prior coverage as defined under the portability norms of the extant IRDAI regulations. The policy coverage after the expiry of 48 months for any pre-existing disease is subject to being declared at the time of application and must be accepted by the Insurer.
  4. Some of the Domiciliary Hospitalisation benefits may not get covered in this policy:-
    1. Expenses incurred for pre- and post-domiciliary hospitalization
    2. Expenses for the treatment for any of these diseases – Asthma, Bronchitis, Chronic Nephritis and Nephritic Syndrome, Diarrhea and all types of Dysenteries including Gastro-enteritis, Epilepsy, Influenza, Cough and Cold, Pyrexia of unknown origin for < 10 days, Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharyngitis, Arthritis, Gout and Rheumatism
  5. Injury or Illness due to war, invasion, acts of foreign enemies, hostilities, 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 (whether the situation of war is declared or not by the government).
  6. Treatment taken outside India
  7. Injury or Illness caused by or contributed to nuclear weapons or materials
  8. Circumcision (unless necessary for the treatment of a disease, illness or injury which is not excluded)
  9. Expenses for the treatment of eyesight correction due to refractive error < 7.5 dioptres
  10. Expenses for cosmetic or plastic surgery, or any type of treatment that is related to change in appearance unless these are required due to reasons like an Accident, Burn(s), Cancer, or if it is a part of the medically necessary treatment to remove a direct and immediate health risk
  11. Cost of spectacles, contact lenses, hearing aids, crutches, wheelchairs, dentures, artificial teeth and all other external appliances or devices unless specifically covered by the insured
  12. Expenses incurred on Items like television, telephone, etc. incurred during hospitalization and charged in the hospitalization bills
  13. External medical equipment of any kind which is used at home including the cost of instrument used in Sleep Apnoea Syndrome (C.P.A.P), Continuous Peritoneal Ambulatory Dialysis (C.P.A.D) and Oxygen concentrator for Bronchial Asthmatic condition
  14. Dental treatment or surgery of any kind (Unless it is due to an accidental bodily injury)
  15. Convalescence, general debility, “Run-down” condition, rest cure, Congenital external illness, disease, or defect.
  16. Intentional self-injury
  17. Breach of law
  18. Treatment for alcoholism, drug, or any substance of abuse including addictive conditions and consequences.
  19. Venereal disease or any sexually transmitted disease (except HIV or AIDS)
  20. Medical treatment traceable to childbirth (including the complicated deliveries and caesarean sections as well) except ectopic pregnancy.
  21. Expenses towards miscarriage (unless it is due to an accident) and the lawful medical termination of pregnancy during the policy period.
  22. Expenses related to sterility and infertility such as any type of sterilization assisted reproduction services including artificial insemination and advanced reproductive technologies like IVF, ZIFT, GIFT ICSI, Gestational Surrogacy, or reversal of sterilization.
  23. Vaccination or inoculation excluding the animal bite
  24. Dietary supplements and substances bought without any prescription, including but not limited to vitamins, minerals and organic substances.
  25. Correction for Deviated Nasal Septum and Hypertrophied Turbinate (unless caused due to an accident)
  26. Medical Practitioner’s home visit expenses during pre- and post-hospitalization period, including the attendant nursing expenses.
  27. Outpatient Diagnostic, Medical and Surgical procedures or treatments
  28. Non-prescribed drugs and medical supplies
  29. Expenses of any treatment, including surgical management, to make a change in characteristics of the body to those of the opposite sex.
  30. Expenses of treatment caused due to participation in hazardous or adventure sports, like para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, skydiving, deep-sea diving.
  31. Expenses of hospitals where only diagnosis is performed for 24 hours hospitalization. This includes the stay in hospital expenses where there is no regular treatment performed by the Medical Practitioner and can get performed even without hospitalization.
  32. Expenses of health hydros, nature cure clinics, spas, or similar establishments or private beds registered as a nursing home.
  33. Expenses related to enforced bed rest and not for injury or illness treatment. This also includes custodial care either at home or nursing facility, and services for people who are terminally ill to address physical, social, emotional and spiritual needs.
  34. Expenses for diagnostics and evaluation purposes only like any diagnostic expenses not related or not incidental to the current diagnosis and treatment
  35. Ayurvedic, homeopathy, unani, acupuncture, acupressure, osteopath, naturopathy, chiropractic, reflexology and aromatherapy treatment (unless specifically covered under the policy).
  36. Body organ donation by the insured including the complications arising from the donation of organs.
  37. Obesity surgical treatment that does not fulfill the below conditions:-
    1. The surgery should be conducted on the doctor’s advice
    2. The surgery or procedure is supported by clinical protocols
    3. The person undergoing the treatment should be a minimum of 18 years old
Body Mass Index (BMI)
>=40%
>=35% in conjunction with any of the severe comorbidities following the failure of less invasive methods of weight loss-:
Obesity-related cardiomyopathy
Coronary heart disease
Severe Sleep Apnea
Uncontrolled Type 2 Diabetes
  1. Expenses of the unproven treatment, services and supplies in connection with any treatment. These are the treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.
  2. Donor screening or treatment expenses including organ extraction (unless specifically covered in the policy)
  3. Injury or Illness caused while performing duties as a serving member of a military or police force
  4. Service charges, Surcharges, Admission fees, Registration charges, etc, levied by the hospital or nursing home
  5. In respect of the pre-existing diseases, which are disclosed by the insured and mentioned in the policy schedule, the policyholder is not entitled to get the coverage for some specified ICD codes.

Waiting Period for Group Health Insurance SBI Plan

The insurer will pay for the expenses which are related to your pre-existing conditions, surgeries, treatments after the expiry of 90 days waiting period. This exclusion will not apply to claims due to an accident. If any of the specified diseases or procedures fall under the waiting period, longer of the two waiting periods will be applicable. The waiting period for the listed conditions applies even if contracted after the policy or declared and accepted without a specific exclusion.

List of Specific Diseases or Procedures ( With 12 Months Waiting Period)

  1. Any types of gastric or duodenal ulcers
  2. Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty
  3. Surgery on all internal or external tumor including cysts, nodules, breast lump, polyps of any kind
  4. All types of Hernia and Hydrocele
  5. Anal Fissures, Fistula and Piles
  6. Cataract;
  7. Benign Prostatic Hypertrophy
  8. Hysterectomy or myomectomy for menorrhagia or fibromyoma or prolapse of uterus
  9. Non-infective Arthritis, Treatment of Spondylosis / Spondylitis, Gout & Rheumatism
  10. Surgery of Genitourinary tract
  11. Calculus Diseases
  12. Sinusitis, nasal disorders and related disorders
  13. Surgery for prolapsed intervertebral disc (unless it is arising from an accident)
  14. Vertebro-spinal disorders (including disc) and knee conditions
  15. Surgery of varicose veins and varicose ulcers
  16. Chronic Renal failure
  17. Medical Expenses incurred in connection with joint replacement surgery due to Degenerative condition, age-related osteoarthritis and osteoporosis unless such Joint replacement surgery is necessitated by an accidental bodily Injury.

List of Specific Diseases or Procedures (With 90 Days Waiting Period)

  1. Hypertension, Heart Disease and related complications
  2. Diabetes and related complications

List of Specific Diseases or Procedures (With 30 Days Waiting Period)

  1. Expenses related to the treatment of illness within 30 days of the first policy commencement date are excluded, except the claims arising due to an accident.
  2. If you have continuous coverage for more than 12 months, this exclusion may not apply
  3. The waiting period applies to the enhanced sum insured in the event of granting a higher sum insured subsequently.

Group Health Insurance SBI Plan Free Look Period

Your policy Free Look Period will start from the date of receipt of the policy document. The insured person is allowed a 15-day free look period to review the terms and conditions of the policy and return the same if not acceptable. If you haven’t made any claims during the Free Look Period, you will get:-

  1. A refund of the paid premium paid minus medical examination expenses and stamp duty charges
  2. If risk has already commenced and the option of return is exercised, the company will give a deduction towards the proportionate risk premium for the period of cover.
  3. If only a part of the insurance coverage has commenced, the premium commensurate with the insurance coverage.

Group Health Insurance SBI Claim Procedure

The insured can claim the sum insured when he/she is hospitalized due to any of the covered illness or injury. There are two types of methods by which you can get the money from your insurer to pay the hospital bills.

Reimbursement

First, you should consult a doctor and follow the advice of treatment as recommended, try to minimize the quantum of any claim that might be made under this policy, and intimation to this effect can be forwarded to the insurer accordingly. In respect of the post-hospitalization claim, the insured must lodge it within 15 days from the completion of post-hospitalization treatment, subject to a maximum of 75 days from the date of discharge.

You will need to submit yourself for examination by the insurer’s medical advisors as considered necessary by the insurer. In such an event, the insurer will bear all expenses incurred with the prior approval or permission of the insurer to the insured person for making himself available for the medical examinations.

After that, submit all original bills, receipts, certificates, information and evidence from the attending Medical Practitioner, Hospital, Diagnostic Laboratory as required by the insurer.

On receipt of such intimation from the insured, the insurer or administrator is entitled to carry out the examination and obtain information on any alleged Injury or disease to find whether it requires hospitalization, if and when the insurer may reasonably require.

Cashless

Your administrator will provide you a guide and identity card. In the user guide, you will have the following information:-

  1. Contact details of all administrator offices
  2. Website address of the administrator
  3. List of network providers along with their contact details
  4. The procedure of getting cashless benefits at the network providers
  5. And the claim submission guidelines

Intimation of Group Health Insurance SBI Claims

In an event of the Accidental Bodily Injury or Disease first occurring during the Policy Period and that may have caused the Insured Person to be hospitalized, a hospitalization benefit will be payable to the insured as per the policy conditions. This may result in a claim as per policy terms and condition, as a condition precedent to the insurer’s liability, the insured must provide the intimation to the insurer immediately and in any event within 48 hours from the date of hospitalization.

You will need to submit the below-mentioned documents for the processing of hospitalization claims within 30 days from the date of discharge from the hospital. However, the Insurer at his sole discretion may relax this condition subject to satisfactory proof or evidence being produced on the reasons for delay beyond the stipulated 30 days to up to 60 days. The intimation can be sent to the insured via email, telephone, fax, in person, letter, or any other suitable mode.

Group Health Insurance SBI Claim Submission

  1. Submit the claim documents to the administrator. The following is the list of documents for claim submission:-
  2. Duly filled Claim form
  3. Valid Photo Identity Card
  4. Original Discharge card, certificate, or the death summary
  5. Prescription for a diagnostic test, treatment advise, medical references copy
  6. Original investigation reports
  7. Itemized original hospital bills, original receipts and related original medical expenses receipts, pharmacy bills with prescriptions.

Group Health Insurance SBI Policy Claim Processing

On receipt of the claim documents from the Insured, the insurer or administrator shall assess the admissibility of claims as per the policy terms and conditions. Upon the satisfactory completion of the assessment and admission of claims, the Insurer will make the payment as per the contract. In case the claim is repudiated, the insurer will inform the claimant about the same in writing with the reason for repudiation.

Penal Interest Provision

The company has the right to settle or reject a claim, as the case may be, within 30 days from the date of receipt of the last necessary document. In case of delay in the claim payment, the company is liable to pay interest to the policyholder from the date of receipt of the last necessary document to the date of payment of claim at 2% above the bank rate.

However, where the circumstances of a claim warrant an investigation in the opinion of the company, it will initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of the last necessary document. In such cases, the company settles or rejects the claim within 45 days from the date of receipt of the last necessary document.

In case of delay beyond the stipulated period of 45 days, the company will be liable to pay interest to the policyholder at 2% above the bank rate from the date of receipt of the last necessary document to the date of claim payments.

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