Benefits covered the actual cost of health-related expenses from hospitalization for over 24 hours due to any major health event affecting the household, such as a catastrophic illness, an accident, or the birth of a child. The policy provided coverage for the period of one year. Members and their dependents received the same benefits. Conditions excluded from coverage included HIV/AIDS, reproductive health, drug- or alcohol-induced conditions, and conditions not requiring hospitalization.
While the insurance was mandatory for all clients taking a new loan, the client could choose to cover up to three additional family members, with the premium adjusted accordingly. Depending on the level of coverage, the client paid a premium of 1.9-2.5% of the total sum assured for the insurance policy. The client paid an additional 0.8-1.5% of the total sum assured to SKS as an administrative fee. SKS management chose not to require a co-payment or deductible, believing that such a requirement would decrease the popularity of the product among clients. (as of 2008).
There were two ways which an insured member could claim benefits. If she or an insured dependent received treatment at a “network” hospital, she could receive cashless benefits, without paying any cash out-of-pocket towards covered expenses. Alternatively, an insured individual could receive treatment at an “out-of-network” hospital, but would have to pay for treatment upfront, submit claims documentation to SKS, and wait for reimbursement in 45-90 days. “Cashless” benefits became effective 15 days after enrollment, while “out-of-network” benefits became effective immediately.
