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Apollo Maxima Health Plan Prospectus



•           This policy covers persons in the age group 91 days onwards. The maximum entry age is 65 years.

•           There is no maximum cover ceasing age in this policy.

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•           The policy will be issued for a 1 year period.

•           This policy can be issued to an individual and/or family. The family coverage in on floater basis and the coverage will be available for two adults & two adults + up to 2 children.

•           The family includes spouse, dependent children and dependent parents.

•           The premium under floater coverage will be charged on the age of the eldest insured member.

Salient Features & Benefits

Outpatient Module

We will issue Entitlement Certificate to the Insured Person for availing Outpatient benefits with the Network service provider.

1.         Outpatient Consultations - Outpatient consultations (In Network or Non-Network) by a general Medical Practitioner(s) or a specialist Medical Practitioner(s).

2.         Diagnostic Tests within specified Network - Outpatient diagnostic tests taken by the Insured Person from a Network diagnostic centre (not necessarily to be prescribed by Network Medical Practitioner).

3.         Pharmacy within specified Network - Medicines purchased by the Insured Person from a Network pharmacy, provided that such medicines have been prescribed in writing by a Medical Practitioner (not necessarily to be Network Medical Practitioner).

4.         Outpatient Dental Treatment within specified Network - Any necessary dental treatment taken by an Insured Person from a Network dentist provided that We will not pay for any dental treatment that comprises cosmetic treatment.

5.         Spectacles, Contact lenses within specified Network - Either one pair of spectacles or contact lenses, provided that these have been prescribed for the Insured Person by a Eye specialist network Medical Practitioner(s).

6.         Annual Health Check Up within specified Network - A health check-up for the Insured Person in a Network Hospital. [This benefit is not available to the Insured Persons above the age of 45 years in the first Policy Year and to the Insured Persons below 18 years of age.]

The above mentioned benefits (2, 3, 4, 5 and 6) are covered in Network only.

Outpatient benefit Network is available in following cities (Chennai, Delhi, Mumbai, Hyderabad, Bengaluru, Ahmedabad, and Kolkata).

The list of network service providers is available on our website www.apollodkv.co.in

If an Entitlement Certificate has been used and results in treatment to which Inpatient Module responds, then we would be refunding the Entitlement Certificate used for pre-hospitalization by issuing fresh Entitlement Certificate.

Inpatient Module

1.         In-patient Treatment – covers hospitalization expenses due to an illness or accident. We will pay for the medical expenses for Room rent, boarding expenses, Nursing, Intensive care unit, Medical Practitioner(s), Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, Medicines, drugs and consumables, Diagnostic procedures, Cost of prosthetic & other devices or equipments if implanted internally during a Surgical Procedure

2.         Pre-Hospitalization - The Medical Expenses incurred in 30 days immediately before the Insured Person was hospitalized. It can be increased to 60 days if claim is intimated 5 days before hospitalization.

3.         Post-Hospitalization - The Medical Expenses incurred in 60 days immediately after the Insured Person was discharged post Hospitalization. It can be increased to 90 days if claim is intimated 5 days before hospitalization.

4.         Day-Care procedures – The Medical Expenses for 140 Day care procedures which do not require 24 hours hospitalization due to technological advancement.

5.         Domiciliary Treatment - The Medical Expenses incurred by an Insured Person for availing medical treatment at his home which would otherwise have required Hospitalization.

6.         Organ Donor - The Medical Expenses for an organ donor’s treatment in the event of organ transplantation.

7.         Emergency Ambulance – Expenses Up to Rs. 2000 per hospitalization for utilizing ambulance service for transporting Insured Person to Hospital in case of an emergency or from one hospital to another if medical services required are not available.

8.         Maternity Expenses – Medical Expenses for maternity including pre-natal and post-natal expenses after a waiting period of 4 years.

9.         Newborn baby – Optional Coverage for newborn from birth (day 1 - 90) for In-patient Treatment benefit, subject to acceptance of proposal and premium payment in full.

10.       Daily Cash for choosing shared accommodation- Daily cash amount per day if the Insured Person is hospitalized in Shared Accommodation in a Network Hospital and hospitalization exceeds 48 hrs.

11.       Daily Cash for accompanying an insured child- Daily cash amount for 1 accompanying adult if insured child under 12
years is hospitalized and hospitalization exceeds 72 hrs.

Optional Benefit:       Critical Illness benefit provides lump sum benefit for listed Critical Illness. The benefit amount is payable once the Critical Illness is diagnosed during the policy period and the Insured Person survives 30 days after the diagnosis. This benefit can be opted on payment of additional premium. This benefit if opted is applicable to all family members on Individual Sum Insured Basis equivalent to Rs 300,000/-. This benefit will not be renewed beyond 70 years of age.

Renewal Incentives:
Outpatient Module:
Carry Forward Bonus
- If any available Entitlement Certificates are not used by Insured Person in a Policy Year, then We will carry forward 50% of these Entitlement Certificates to the next Policy Year except for Annual Health Check Up.

Process for obtaining Carry Forward Entitlement Certificates: You have to send us all unused Entitlement Certificates before renewal (grace period of 15 days from the due date of renewal can be provided). After verifying the Entitlement Certificates and checking the admissibility of Carry Forward Bonus as mentioned above, fresh entitlement certificates will be issued within 30 days of the receipt of the unused Entitlement Certificates provided that the policy is renewed with Us without a break.

In-patient Module:
Cumulative Bonus - We will offer Cumulative bonus of 10% of the Sum Insured for every claim free year accumulating up to 50%. In the event of a claim, the Cumulative bonus will be reduced by 20% of sum insured on renewal.

Key Exclusions: [Applicable to In-patient Module and Critical Illness benefit]
•           Any treatment within first 30 days of cover except any accidental injury.
•           2 years exclusion for specific diseases.
•           Coverage for Pre-existing diseases from 4th year onwards.
•           Expenses arising from HIV or AIDs and related diseases.
•           Abuse of intoxicant or hallucinogenic substance like drugs and alcohol.
•           War or act of war, nuclear, chemical or biological weapon and radiation of any kind.
•           Non-allopathic treatment.

Sum Insured:             Inpatient Sum Insured per policy of Rs 300,000, Outpatient Sum Insured per policy as mentioned in Schedule of benefits and Critical Illness (Optional Benefit) Sum Insured per insured Rs 300,000/-.

Terms of Renewal
1. We offer life-long renewal unless the Insured Person or any one acting on behalf of an Insured Person has acted in a dishonest or fraudulent manner or any misrepresentation under or in relation to this policy or the Policy poses a moral hazard.

2. Maximum Age - There is no maximum cover ceasing age in this policy. For Optional Benefit of Critical Illness maximum cover ceasing age in this policy would be 70 years.

3. Waiting Period - The Waiting Periods mentioned in the policy wording will get reduced by 1 year on every continuous renewal of your Maxima Insurance Policy.

4. Renewal Premium – Renewal premium are subject to change with prior approval from IRDA.

• Completed proposal form
• Pre Policy Check-up (PPC) depending on the age and sum insured. For accepted PPC cases, we will reimburse 100% of the expenses incurred subject to maximum of Rs. 2000/- per insured person.


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Your Comments

By veda vallika on Nov 29, 2010 5:58 PM

hi.......................................excellent treatement.............................
Did you know?
Medimanage is the only Dedicated Health Insurance Broker in India.
Medimanage has managed more than 25000 claims end-to-end.
Medimanage insures more than 2 Lakh lives every year.
I would like to thank you for all the help you provided I appreciate and thank you for the efficient and highly professional handling of my claim.

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