Max Bupa Proposal Form

8/19/2019 Max Bupa Proposal Form

1/14

1

Heartbeat Health Insurance Policy Proposal Form

Please fill up this form in CAPITAL LETTERS for yourself and each proposed insured person.

1. Proposer Details

Title

Name

City District

Current Address

Permanent Address

City District

State Pin code

Address for Communication Permanent Current

(Mandatory for premium above Rupees one lac)PAN No.

Marital Status Single Married Divorced Widow(er) Separated

Bank Details:

Bank Name

Branch

IFSC Code

City

Account Type CurrentSavings

Annual Gross Income (in Rs.)

If self employed, specify business/occupation

If salaried, specify designation

Occupation Salaried Self employed Student Housewife Others

Highest Educational Qualification Lesser than matriculation Matriculation Graduate

Post Graduate Professional Course

Nationality

E-mail ID

State Pin code

Account Number

Phone No. STD Code Mobile No.Landline No.

(atleast one of landline and mobile number should be provided)


2/14

1. Plan details

Policy Type Individual Family Floater Family First

If Family Floater, number of persons to be covered 1 Adult + 1 Child 1Adult + 2 Children 1 Adult + 3 Children1Adult + 4 Children 2 Adults 2 Adults + 1 Child

2 Adults + 2 Children 2 Adults + 3 Children 2Adults + 4 Children If Family First, number of person to be covered Adults__________ Children __________ Please tick/fill the relevant boxes.

2

4. Details of Persons Proposed to be Insured

3. Sum Assured (in Rupees)

2 Lacs 3 Lacs 5 Lacs 7.5 Lacs 10 Lacs 15 Lacs 20 Lacs 50 Lacs15 Lacs 20 Lacs 50 Lacs 1Cr

3.1 Individual/Family

Floater:

Silver Gold Platinum

Please tick the relevant boxes.

3.2 Family First:

Silver Individual Base Sum Insured Rs.1Lac Rs.2Lacs Rs.3Lacs Rs.4Lacs Rs.5Lacs

Floater Sum Insured Rs.3Lacs Rs.4Lacs Rs.5Lacs Rs.10Lacs Rs.15Lacs

Gold Individual Base Sum Insured Rs.1Lac Rs.2Lacs Rs.3Lacs Rs.4Lacs Rs.5Lacs

Rs.10Lacs Rs.15Lacs

Floater Sum Insured Rs.3Lacs Rs.4Lacs Rs.5Lacs Rs.10Lacs Rs.15Lacs

Rs.20Lacs Rs.30Lacs Rs.50Lacs

Platinum Individual Base Sum Insured Rs.5Lacs Rs.10Lacs Rs.15Lacs

Floater Sum Insured Rs.15Lacs Rs.20Lacs Rs.30Lacs Rs.50Lacs

2. Proposed policy term1 year 2 year

Coverage Selection: Section I

P r o p o s e d I n

s u r e d

Permanent Address

Current Address ( ) same as permanent address

City District

State Pincode

City District

State Pincode

Address for eldest person proposed to be insured

Address for Communication Permanent Current

Title Name

Gender Male Female Height (cm) Weight (kg) Date of Birth

Relationship with Proposer Self Spouse Son Daughter Daughter-in-law Father Mother Son-in-law

Father-in-law Mother-in-law Grandfather Grandmother Grandson Granddaughter Others(Please specify)______

Nationality

Highest Educational Qualification Lesser than matriculation Matriculation Graduate Post Graduate Professional Course

Occupation Salaried Self employed Student House wife Others



P r o p o s e d

I n s u

r e d

1

Title Name




Nationality





P r o p o s e d I n

s u r e d

2


3/143

P r o p o s e d

I n s u r e d

8

Title Name




Nationality





P r o p o s e d

I n s u r e d

3

Title Name




Nationality





P r o p o s e d

I n s u r e d

4

Title Name




Nationality





P r o p o s e d

I n s u r e d

5

Title Name




Nationality





P r o p o s e

d

I n s u r e d

6

Title Name




Nationality





P r o p o s e d I n

s u r e d

7


4/144

Note: Premium is for individual age bands and 3 geographical zones. If you need more space please use extra sheets.

Title Name




Nationality





P r o p o s e d

I n s u r e d

8

Title Name




Nationality





P r o p o s e d

I n s u r e d

9

Title Name




Nationality





P r o p o s e d

I n s u r e d

1 0

Title Name




Nationality





P r o p o s e d

I n s u r e d

1 1

Title Name




Nationality





P r o p o s e d

I n s u r e d

1 2


5/14

If you have answered yes in response to any of the questions in section 6, please give full details here. If you need more space please use

extra sheets. If you are unsure whether any details are relevant, please include them.

7. Additional Information

Name ofProposedInsured

Therelevantquestionnumber

fromsection 6(MedicalHistory)

Please specify asaccurately as possiblethe symptoms or the

medical condition.Where applicable,

please state the areaof the body affected

(e.g. right leg, left eye).

When did thesymptoms start

and/or when wasthe treatment

completed?

What treatmentdid you receive and

when (please includedates of treatmentand any medication

prescribed)?

What was the outcome ofthe treatment (e.g. ongoing,complete recovery, recurrent

or likely to recur)?

Note: In addition to the above, We may have additional questions for you or may ask you to undergo medical tests to complete your full medical assessment

1) Within the last 2

years, have you

consulted a doctor

or a healthcare

professional?


years, have you

been to a hospital

for an operation

and/or an

investigation (e.g.

scan, x-ray, biopsy

or blood tests)?

3) Do you take

tablets, medicines

or drugs on a

regular basis?


months have you

experienced any

health problems or

medical conditions

which you/proposed

insured person

have/has not seen a

doctor for?

Yes No

ProposedInsured

Name

Yes No

ProposedInsured 1

Name

Yes No

ProposedInsured 2

Name

Yes No

ProposedInsured 3

Name

Yes No

ProposedInsured 4

Name

Yes No

ProposedInsured 5

Name

Yes No

ProposedInsured 6

Name

Yes No

ProposedInsured 7

Name

Yes No

ProposedInsured 8

Name

Yes No

ProposedInsured 9

Name

Yes No

ProposedInsured 10

Name

Yes No

ProposedInsured 11

Name

Yes No

ProposedInsured 12

Name

Questions

5

In order for Us to service you fully, please answer the questions below accurately to the best of your knowledge. Please ensure that you are

fully informed about the standard waiting periods and permanent exclusions that apply to the Max Bupa Health Insurance Policies.

6. Medical History

In the event of the death of the proposer any payment due under the policy shall become payable to the nominee proposed in the form and

the receipt of the proceeds by such nominee would be sufficient discharge to the Company. Nominee for all other persons proposed to be

insured shall be the proposer himself/herself. The following section is to be filled by the proposer:

Nominee Name Relationship with Proposer Address of Nominee

5. Nomination


6/14

The following are the permanent exclusions under the Policy. For further details on the exclusions, please refer to the terms and conditions ofthe Policy.

Addictive conditions and disorders; Ageing and puberty; Artificial life maintenance; Circumcision; Conflict and disaster; Congenital conditions; Convalescenceand Rehabilitation; Cosmetic surgery; Dental/oral treatment; Drugs and dressings for OPD Treatment or take-home use; Experimental treatment; Eyesight;Health hydros, nature cure, wellness clinics etc; Hereditary conditions (specified); HIV and AIDS; Items of personal comfort and convenience; AlternativeTreatment (except for Consultation and Diagnostic Tests for Platinum policy holders only); Obesity; Out-patient Treatment; Psychiatric and PsychosomaticConditions ; Reproductive medicine - Birth control & Assisted reproduction; Self-inflicted injuries; Sexual problems and gender issues; Sexually transmitteddiseases; Sleep disorders; Speech disorders; Treatment for developmental problems; Treatment received outside India (except for treatment undertakenunder “Emergency Medical Evacuation and hospitalization (for platinum Policyholders only)” or “Specified Illness cover for treatment abroad (For PlatinumPolicyholders only)” of the Policy document); Unlawful Activity; Unrecognised physician or Hospital, Genetic disorders; any other such permanent exclusionsas may be specified in the Schedule.

For all Insured Persons who are above 60 years of age as on the date of commencement of the first Policy Period, the conditions listed below will be subjectto a waiting period of 24 months and will be covered in the third Policy Year as long as the Insured Person has been insured continuously under the Policywithout any break.

Stones in the urinary system (example kidney/bladder) • Stones in billiary system (example gall stones) • Cataract • Benign prostatic hypertrophy • Mennerghia fibroinyoma, uterine prolapse including any condition requiring hysterectomy • Piles (Haemorrhoids) • Hernia (inguinal/umbilical and gastric) • Degenerative disorders of knee/hip • Chronic renal failure or end stage renal failure • Retinopathy • Diabetes and related treatments

If any Insured Person is 65 years of age or over on the date of commencement of the Policy, then max Co-payment would be applicable in accordance withthe table provided below, if any Insured Person is 65 years of age or over on the date of commencement of the current Policy Year, then it is agreed thatWe will pay the percentage provided in the table below of the amount We assess for payment or reimbursement in respect of any claim made by thatInsured Person and the balance will be borne by the Insured Person.

6

Co-payment contribution table

No. of Years of Continuous renewal at or later than the age of 65 years Percentage of any assessed claim amount payable by Us

0 yr 80%1yr 85%

2 yr 90%

3 yr 95%

4 yr or more 100%

There could be certain declined risks as per the underwriting norms of the Company.

Based on our assessment of your health some conditions may have waiting periods or exclusions applicable to any/all of the

Proposed Insured.

Optional Coverage Selection: Section II

1. Deductible or Co-Payment

a. Cost Sharing option(Available only for Silver SI options of Individual and Family Floater Plans):

By choosing one of the cost sharing options below you can get the corresponding discount in your premium calculations for this policy,

i. 1 Lac annual aggregate deductible. ii. 2 Lacs annual aggregate deductible. iii. 3 Lacs annual aggregate deductible.

Deductible option Premium Discount percentage You can choose only one option marking “Yes”

1 Lac annual aggregate deductible. 25%

2 Lacs annual aggregate deductible. 33%

3 Lacs annual aggregate deductible. 45%

b. Optional Co-payment for insured persons younger than 65 years: By choosing one of the two co-payment option below you can avail areduction in the premium of this policy. This option is only available for policies where none of the proposed insured persons are 65 years

or older.

Co-payment and discount option Premium Discount You can choose only one option marking “Yes”

10% co-payment for all claims that you submit to Us. 10%

20% co-payment for all claims that you submit to Us. 20%

2. Enhanced geographical coverage for

a. Emergency Medical Evacuation and Hospitalization benefit and

b. Specified Illness treatment abroad benefit.Platinum customers with sum insured of 15 lacs, 20 lacs, 50 Lacs, 1 Cr or with Family First option can enhance their coverage for the above 2benefits, to include pre-authorized treatment in US and Canada as well, by paying additional premium.Would you like to include US and Canada in the covered geographic area for the above 2 benefits?

Yes No3. Health Relationship Loyalty Program

You can choose anyone from the below mentioned options of Health Relationship Loyalty Program if you renew the policy continuously without any break.

Option 1: Loyalty Points worth 10% of last paid premium which can be redeemed against various products and services

Option 2: 10% additional Sum Insured of expiring base Sum Insured upto a max of 50% of current base Sum Insured


7/147

5. Caution

You are obliged to make a full and frank disclosure of all facts material to the assumption of risk in relation to you and every person proposed to

be insured that would influence our decision to issue policy, or the terms on which it is issued and You must not misrepresent any information

to Us. The obligation continues until the Policy is issued, and does not end with the submission of this proposal form. If therefore, there is any

change in the information given herein or new information comes to light before the Policy is issued, then you must inform Us of the same in

writing without delay. If there is insufficient space to provide additional information, whether as requested or otherwise, then please attach an

extra sheet duly signed. If the disclosure obligations are breached then this may render any policy issued void.

4. Renewal Payment Sign-up

Payment of renewal premium of your health insurance policy can be made every year through continuing your existing ECS instructions

with Us. Under this option, your policy can be renewed promptly, but subject to you completing all additional requirements of

information and documentation as may be required by Max Bupa.

Would you like to opt for the ECS renewal option at this stage?

Yes No

If you have chosen ‘Yes’ above please fill up the ECS Mandate form attached along with this form.

2. Checklist of Documents

3. Existing Insurance Details

Is the proposer or any of the persons proposed to be insured already insured under or proposed for a health insurance policy for

in-patient hospitalisation with Max Bupa Health Insurance Company Limited or any other insurance company.

If yes, please indicate below the Policy/Application number(s). (Please mention the application number in case of a pending proposal)

Since when have you been continuously insured (please provide the insurance history of atleast last 3 years for

each proposed insured person if they have been continuously insured)

Name Policy No. / Application No. Insured from (date) To (date) Sum Insured Claim details (if any)

In addition to the information given above, please also submit to Us (as an annexure to this proposal form) all the policy documentsrelating to the existing policy in order to avail the portability benefit from your existing insurance policy.

3. Existing Insurance Details

a. ID Proof Passport PAN Card Voter ID Driving License Letter from Recognised Public Authority Others

b. Age Proof School/College Leaving Certificate Passport PAN Card Voter ID

Driving License Letter from Recognised Public Authority Others

Family Physician’s Name

1. Family Physician’s Details

Address

City District

State Pin code

General Selection: Section III


8/148

Acknowledgment

Proposal Form No. Date

We acknowledge with thanks the receipt of your proposal and amount by Cash/Cheque/Demand Draft/ Others ________________________ of

amount of Rs. ___________________________ dated ___________________________ drawn on ____________________________ .Neither the submission to Us of a completed proposal for insurance nor any payment for any policy sought obliges Us to agree to issue a policy,which decision is and always shall be in our sole and absolute discretion. If We accept a proposal for insurance, it shall be subject to the policyterms and conditions and We shall have no liability whatsoever if premium is not received by Us in full and in time or is not realized. If We do notaccept the proposal, We will inform you and refund the payment, if any, received from you without interest.

Signature of the receiver and office seal

8. Vernacular Declaration

I hereby declare that I have fully explained the contents of the proposal form and all other documents incidental to availing the health insurance

from Max Bupa Health Insurance Company Limited to the Proposer in the language understood by him/her. The same have been fully

understood by him/her and the replies have been recorded as per the information provided by the Proposer. Replies have been read out to, fully

understood and confirmed by the Proposer.

Declarant’s Name:

Address:

City Pin Code

Signature of declarant: Signature of applicant in vernacular:

7. Declaration

I/We hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars

given by me are true and complete in all respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these

other persons.

Dated:

Place

Signature of the Proposer

Name of Proposer

6. Authorisation (Please read carefully and put a check mark against each before signing)

I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting

policy of the insurance company and that the policy will come into force only after full receipt of the premium chargeable.

I/We further declare that I/We will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer

after the proposal has been submitted but before communication of the risk acceptance by the company.

I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at anytime has attended on

the life to be insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the life

to be assured/proposer and seeking information from any insurance company to which an application for insurance on the life to be

assured/proposer has been made for the purpose of underwriting the proposal and/or claim settlement.

I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal

underwriting and/or claims settlement and with any Government and/or Regulatory authority.

I consent to and authorize any of Company’s authorized representatives not being direct employees of the Company to seek medical

information required for the purpose of policy issuance or claim settlement under this policy from any hospital/medical practitioner that I or any

person proposed to be insured/insured has attended or may attend in future concerning any disease or illness or injury.

Authorization for electronic policy fulfillment and service communications

I hereby consent that the policy documents may be sent to me by email at _______________________________(Please provide us your e-mail id)

I hereby consent to and authorize Max Bupa Health Insurance Company Limited( “ Company”) to make welcome calls, service calls or any other

communication (electronic or otherwise) with respect to the proposed or existing policy of the Company from time to time.

Dated Signature of the Proposer

Place Name of Proposer


9/149

Processed By Date Approved By Date

Customer ID

STATUTORY WARNING AS PER SECTION 41 OF THE INSURANCE ACT 1938 PROHIBITION OF REBATESPayment of rebates is expressly prohibited under Section 41 of the Insurance Act, 1938.1. No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in

respect of any kind or risk relating to lives or property in India any rebate of the whole or part of the commission payable or any rebate of thepremium shown on the policy nor shall any person taking out or continuing a policy accept any rebate except such rebate as may be allowed inaccordance with the prospectus or tables of the Insurer.

2. Any person making default in complying with the provisions of this Section shall be punishable with fine, which may extend to five hundred rupees.

Bank Name/Branch

Max Bupa Branch Location Code No.

Business Sourced By: Advisor/DST/Corporate Agency/Other Channels Code No.

Name Code No.

Premium Payment Details:

Amount Date

Credit Card (16 digit no)Cheque/DD No.Cash

For Office Use Only

Proposal Received On: Date

Date : Signature of the Insurance Advisor

Insurance Advisor’s Report

1. Name of the Proposer

2. Are you related to the Proposer? Yes No

3. If yes, nature of relationship?

4. Is this a proposal form for yourself? Yes No

5. Since when do you know the Proposer? Years Months

6. Are you satisfied with the identity of the Proposer? Yes No

7. Does the Proposer have any physical deformity/defect or mental retardation? Yes No

8. Have you explained the exclusions of the policy and has the Proposer personally completed the health declaration? Yes No

9. What is the Proposer’s state of health at the time of making of this proposal form?

10. Do you recommend acceptance of this proposal form considering all the factors, including moral hazard? Yes No

Additional Details for Bancassurance Channel only

Branch Code SP Code RM/LG Code

Customer Account No


10/14

Max Bupa Health Insurance Company LimitedCorporate Office: Block B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044.

Registered Office: Max House, 1, Dr. Jha Marg, Okhla, New Delhi - 110020www.maxbupa.com

‘Max’ and Max Logo are registered trademarks of Max India Limited. ‘Bupa’ and the HEARTBEAT logo are the registered service marks of The British United ProvidentAssociation Limited. All these marks are being used under license by Max Bupa Health Insurance Company Limited. Insurance is the subject matter of solicitation

Neither the submission to us of a completed proposal for insurance nor any payment for any policy sought obliges us to agree to issue a policy,

which decision is and always shall be in our sole and absolute discretion. If we accept a proposal for insurance, it shall be subject to the policy

terms and conditions and we shall have no liability whatsoever if premium is not received by us in full and in time, or is not realised.

If we do not accept the proposal, we will inform you and refund payment, if any, received from you, without interest.


11/14

This page is not a part of the proposal form. In case you want to take the option ofpaying renewal premium through ECS, then you are requested to fill up this ECS form.


12/14


13/14

Insurance is the subject matter of solicitation . Max Bupa Health Insurance Company Limited. IRDA Registrationnumber 145. 'Max', 'Max logo', 'Bupa' and HEARTBEAT logo are trademarks of their respective owners and are beingused by Max Bupa Health Insurance Company Limited under license.

Key Feature Document

Heartbeat

Max Bupa is dedicated towards being fair and transparent with its customers. This document summarizes key features and major exclusions in yourpolicy. Please read it carefully to understand your policy better.

Room Rent/Hospital Accommodation: Indicates the level of room rent a patient is eligible for.

Silver Plan Gold Plan Platinum Plan

Heartbeat Individual Shared Room or 1% of Single Private Room No Limit and Floater the Sum Insured

It is important to note that the total claim amount is deducted if room rent opted is more than the eligibility. For e.g. If the room rent limit in policyfor an insured is Rs.3000/day, you can opts for Rs.6000/day room and the total hospitalisation bill is Rs.50,000/- then we shall pay reasonable andcustomary charges i.e. equivalent of cost of same treatment incurred in Rs.3000/- room rent in the same/equivalent hospital on our network.

Pre Existing Disease (P.E.D): Any condition/illness/injury which the insured person has suffered from before issuance of policy is classified asP.E.D. Claims with respect to P.E.D are not payable till the completion of waiting period i.e. 48 months (in case of silver plan) / 24 months (in case ofgold/platinum plan) since inception of the policy and continuous renewal.

International Medical treatment and Assistance: Emergency medical evacuation and Specified Illness treatment abroad are covered inplatinum plans only. This benefit is applicable worldwide excluding USA and Canada. USA and Canada may be included by paying additionalapplicable premium.

Maternity: Medical expenses for Maternity and all pregnancy related complications are payable post a waiting period of 24 months afterinception of the policy and subject to continuous renewals as per plan eligibility. Both Husband and Wife should be covered under the same policyto avail maternity benefit.

Pre and Post hospitalisation expenses: Expenses incurred 30 days prior to hospitalisation and 60 days post hospitalisation are payable onlyif hospitalisation is accepted for claim payment under the policy. If we have accepted the In-patient claim with a co-payment, then co-payment shallbe applicable for pre and post hospitalisation treatment as well.

Out Patient Benefits: OPD benefits are available in platinum plan only as per plan eligibility.

Optional Co-Payment: Customers less than 65 yrs age have an option to choose either a 10% or 20% co-payment to avail discount on premium.No co-payment shall be applicable below the age of 65 unless this option is specifically chosen.

Compulsory Reducing Co-Payment above the age of 65 Yrs: Reducing co-payment starts at 20% and reduces by 5% for each continuousyear of cover. For e.g. if a customer has a continues coverage of 3 years prior to his/her commencement of 65th yrs of age, then the co-paymentapplicable at the age of 65 yrs shall be 5% and 66th year of age onwards co-payment shall be nil.

Specific waiting period: For all Insured Persons who are above 60 years of age as on the date of commencement of the first Policy Period, 11listed illnesses (such as Piles, Hernia, Degenerative disorders of knee/hip and Retinopathy) are subject to a waiting period of 24 months.

Portability Benefits: Waiver of waiting period(s) is provided to the extent of period and Sum Insured already covered continuously and withouta break with any previous Indian retail health insurance policy as Insured.

Rise in Premium with age: your health insurance premium will increase gradually every year as insured person(s) age increases.

Health Relationship Loyalty Program: The customer has an option to choose at commencement or renewal of the policy, between loyaltypoints or enhancement of sum insured (S.I). The loyalty benefit shall be passed on if the Policy is renewed without any break. Switching from S.Ienhancement to Loyalty point option cannot be done.

Health Check-up: Max Bupa will cover the cost of a health checkup every year in case of Gold/Platinum plan and once in two years in case ofsilver plan.

Member addition/deletion: Any addition or deletion of the member(s) in the policy can be done only at the time of renewal.Free Look Provision: If you do not agree to the terms and conditions of the policy, you may cancel the policy stating reasons within 15 days ofreceipt of the policy document provided no claim(s) have been made. Premium shall be refunded post deducting charges for medical checkup,stamp duty and proportionate risk premium for the period on cover. The free look provision is not applicable at the time of Renewal of the Policy.

NOTE: THESE ARE ONLY SUMMARY OF THE COVERS OFFERED. PLEASE REFER TO THE POLICY WORDINGS FOR COMPLETE DETAILS BEFORECONCLUDING OF THE SALE; THIS DOCUMENT IS ONLY AN INDICATOR FOR KEY BENEFITS IN THE POLICY.

Date: __________________ Signature of Proposer: _______________

Place: __________________ Name of Proposer: _________________


14/14