Arogya Sanjeevani Policy

Brief Overview

From time to time, the Insurance Regulatory and Development Authority of India (IRDAI), brings in innovations and tries to launch modern insurance products that attract more and more people towards general insurance. One such recently launched health insurance plan is the Arogya Sanjeevani Policy. As per the IRDAI, the plan would prove to be helpful for the public as well as private establishments in providing health insurance to their employees. The policy, in both individual and group form, would also cover COVID-19 treatment.

 Introduced on 1st April 2020,  Arogya Sanjeevani Policy now comes with health coverage of INR 3 lakh to INR 10 lakh. The main aim of introducing this plan is that IRDAI wants to reduce the confusion among the consumers regarding the numerous insurance plans that have been put in the market by the health insurance companies. Though all general insurance companies have been allowed to launch this product in the market, the name of the policy cannot be changed. The companies also are not allowed to add any rider or variant or deductible to the policy. However, there would be a cumulative bonus in the form of a 5% increase in the cover for every claim-free year, which can go up to 50%. 

Arogya Sanjeevani Policy - Highlights

• The plan would be available with the same name and can be bought from almost all health insurance companies.
• The plan will be a standard product and would have similar policy wordings throughout.
• The sum insured would be between INR 3 lakh to INR 10 lakh (in multiples of INR 50,000).
• The policyholder would get a benefit of a 5% increase in the cover for every claim-free year, which can go up to 50%.
• No variants, riders or deductibles can be added to the plan.
• The minimum and maximum entry age is 18 years and 65 years respectively, along with lifelong renewability.
• There would be a co-pay facility of 5% for all age groups.
• Whether individual or group form, the policy would cover COVID-19 treatment.

Arogya Sanjeevani Policy - Benefits 

1. Options to Choose Sum Insured
   The sum insured would be between INR 3 lakh to INR 10 lakh (in multiples of INR 50,000), so you can choose one that you seem right as per your budget.
2. Wide Coverage
   The policy would cover you for the expenses incurred during hospitalisation, which include room rent, nursing and boarding, consultation fee, blood tests, etc. Your insurance company may put a per-day cap on the hospitalisation, which would be either up to INR 5,000 or 2% of the sum insured.
3. Co-payment
   There would be a co-pay facility of 5% for all ages.
4. Pre and Post Hospitalisation
   The expenses on treatment that are done 30 days prior and 60 days after the hospitalisation will be covered under this plan.
5. Dental Treatment
   Your expenses on dental treatment, after an injury or a disease, will be covered up to the sum insured.
6. Day Care Treatment
   Day-care treatments, the treatment that requires less than 24 hours of hospitalisation, are covered under this policy.
7. Ambulance Cover
   An on-road ambulance charge would be covered under the plan till a limit of INR 2,000 per hospitalisation.
8. Non-allopathic Treatment
   The expenses that are incurred when you get admission in a recognised hospital for treatment under Ayurveda, Yoga, Unani, Siddha and Homeopathy.
9. Cataract Treatment
   Up to 25% of the sum insured or INR 40,000 for each eye will be borne by the insurance company.
10. Plastic Surgery
    If after an accident or a disease you require plastic surgery, the cost will be borne by the insurer.
11. Mode of Payment
    With this policy you can choose the frequency with which you want to pay the health insurance premium, you can pick from - Monthly, Quarterly, Half-Yearly or Annually.
12. Pre-policy Health Check-up
    A pre-policy medical is not required before the age of 50 years.
13. Cumulative Bonus
    For every claim-free year, the policyholder would get a benefit of 5% increase in the cover that can go up to 50%.
14. Discounts
    If you add your family members to the plan, you would be eligible for discounts on the premium. You can add your:
    • Parents
    • Spouse
    • Children (natural or legally adopted, between the age of 3 months and 25 years, if financially dependent)
    • In-Laws

Arogya Sanjeevani Policy - What is not Covered

Given below is the list of the most common exclusions applied by insurance companies. It is, however, recommended that you check the exclusion policy of the insurance company before buying the policy.

1. The expenses on tests and investigations not related to the ongoing diagnosis and treatment.
2. Obesity/Weight Control.
3. Treatment needed for injury after participation in adventure sports.
4. If you commit a malicious act or a breach of law.
5. If you take treatment from or in a medical practitioner or healthcare centre that is specifically excluded.
6. Domiciliary hospitalisation is not covered.
7. Maternity expenses, except due to accident.
8. Self-inflicted injuries are not covered.
9. Treatment that is required because of any kind of intoxication use or misuse is not covered.
10. Treatments for infertility, sterility,  birth control, surrogate or vicarious pregnancy will not be covered (unless opted for).
11. Any treatment that is taken in a foreign land will not be covered.

Arogya Sanjeevani Policy - Other Important Details

1. Free Look Period
   15-day, from the date of purchase, is a time period given to you to review the terms and conditions of the policy. In case you feel that the policy does not suit your requirements, you can return the policy. A refund will be initiated if no claims have been made, after subtracting the cost of pre-acceptance of medical screening, stamp duty charges and proportionate risk premium.
2. Tax Benefits
   The premium amount that you pay towards Arogya Sanjeevani Policy will be exempted under Section 80D of the Income Tax Act.
3. Grace Period
   When the policy reaches its expiry date, you have a 15-day grace period to renew the policy. Once the grace period is over, your policy will lapse. Keep it in mind, that you would not be able to avail any policy benefits during the grace period.
4. Cancellation of the Policy
   The circumstances under which a policy may be cancelled are:
   • If you do not renew your policy within the grace period, your policy will be cancelled.
   • If you have acted in a fraudulent manner, the company can cancel your policy.
   • If the policyholder dies, the policy will end.
   • If you want to cancel the policy, you would have to submit a written request. If you have not made any claims, the refund will be on the following rates:

Waiting period
The waiting period in Arogya Sanjeevani Policy can be classified into 3 types:

• Waiting Period for 30 days
  The treatments that you undergo within the initial 30 days from date of purchase will not be covered under this policy. However, accidental injuries, if any will be covered.
• Waiting Period for 2 years
  Benign ENT Disorders, Tonsillectomy, Mastoidectomy, Tympanoplasty, Hysterectomy, Adenoidecto, All internal and external Benign Tumours, Polyps of any kind, including Benign Breast Lumps, Cysts, Benign Prostate Hypertrophy, Cataract and age-related eye ailments, Gout and Rheumatism, Hernia of all types, Hydrocele, Non-Infective Arthritis, Gastric/ Duodenal Ulcer, Fissures and Fistula in Anus, Piles, Pilonidal Sinus, Sinusitis and related disorders, Prolapsed Intervertebral Disc and Spinal Diseases.
• Waiting Period for 4 years
  For the treatment of the following, there is a waiting period of 4 years:
  • Joint Replacement, unless due to an accident.
  • Osteoarthritis and Osteoporosis, which are age-related.

Arogya Sanjeevani Policy - Renewal

It is highly recommended that you renew your policy before it expires or at least in the grace period. At the time of renewal, you can make the following changes in your policy:

• While renewing your policy, you can change the amount of sum insured that you had selected at the time of purchase. You can either increase or decrease the sum insured.
• If a dependent child, over 18 years of age, becomes financially independent during the policy term, then at the time of renewal he/she would be removed from the policy. A separate policy may be purchased for/by them.
• If you had a claim-free year, at the time of renewal, you would be eligible for a 5% discount in the form of a cumulative bonus.

Arogya Sanjeevani Policy - Eligibility

Arogya Sanjeevani Policy - Claim Process

When you wish to make a health insurance claim, there are two ways to proceed-

Reimbursement Claims
In case of a reimbursement claim, you have to submit your details, the Claim Form along with other treatment-related documents to the Insurance Company or the TPA within 30 days from date of discharge. 
The post-hospitalisation expenses must be submitted within 15 days of completion of the post-hospitalisation expenditure.

Documents Required for Reimbursement Claims

• Filled and signed pre-authorisation form
• PAN card
• Health card, if issued
• Police FIR, if reported
• NEFT details, along with a cancelled cheque
• Doctor’s consultation
• Doctor’s prescriptions - medicines or/and diagnostic tests
• All bills and receipts
• Invoice of transplants, if applicable
• Nature of Illness and the treatment required
• Detail of individual medical services
• Investigation reports
• All diagnostic and pathological reports
• Original discharge summary, with the date of admission and discharge history

Cashless Claims
 A cashless claim facility can only be availed at a hospital that has a collaboration with the insurance company. When you go for planned treatment, you need to get pre-authorisation from the insurance company or the authorised TPA 48 hours before treatment. Once the pre-authorisation is received, the treatment can be carried out. In case of emergency treatment, for pre-authorising the cashless facility, the company must be informed within 24 hours after hospitalisation or treatment.

Documents Required for Cashless Claims

• Filled and assigned pre-authorisation form
• Copy of health card, if issued by the company
• Photo ID of insured member
• Doctor’s consultation
• Investigation reports
• The rest of the necessary documents would be provided by the hospital on your behalf.

Arogya Sanjeevani Policy - Review

With the coronavirus still hovering over, many people have realised the importance of having health insurance. The treatment of COVID-19 can be expensive and thus keeping it out of reach for a big percentage of citizens. An affordable and easy-to-understand plan, Arogya Sanjeevani Policy can be instrumental in bringing hospitalisation in everyone’s budget. If you are contemplating to buy an inexpensive health insurance plan for family, that offers you adequate health cover, you can surely consider Arogya Sanjeevani Policy.