This policy has been designed to cater to the needs of our Senior Citizens. It covers Hospitalization and Domiciliary Hospitalization Expenses under Section I as well as expenses for treatment of Critical Illnesses ,if opted for, under Section II. Diseases covered under Critical Illnesses are as under:

•          Coronary Artery Surgery
•          Cancer
•          Renal Failure i.e. Failure for both kidneys
•          Stroke
•          Multiple Sclerosis
•          Major Organ Transplants like kidney, Lung, Pancreas or Bone marrow
•          Paralysis and blindness at extra premium

Critical Illness cover is an optional cover under the policy. Persons who will not opt for critical illness cover are entitled  to Hospitalization and Domiciliary hospitalization expenses cover for those diseases categorized above as critical illness but up to the limit of Sum Insured under Section I i.e. under Hospitalization and Domiciliary Hospitalization Expenses and the claim for those diseases will be paid on reimbursement basis or as cashless hospitalization. Person opting for Critical Illness cover may opt for claim either under Section I or Section II(if not hospitalized) or under both sections for those diseases categorized above as Critical Illnesses but claim under Section I will be paid either on reimbursement basis or as cashless hospitalization if it is otherwise admissible. If in any policy year a critical illness is diagnosed and claim paid thereafter, in subsequent renewals the person may avail cover both under Section I & II but with the exclusion, both under Section I & II, of that particular critical illness which has been diagnosed and claim paid in the preceding policy year.

Sum Insured:  Sum Insured is fixed per person.

Under Hospitalization & Domiciliary Hospitalization Cover sum Insured is Rs.1,00,000/-

and under Critical Illness cover Sum Insured is Rs.2,00,000/-.

Age Group:  For fresh entry in to the scheme-60 years to 80 years. However, for renewal, age limit will be extended up to 90 years in which case the premium of 76-80 age band will be loaded by 10% up to 85 years and 20% up to 90 years of age.

Preacceptance Medical Check up: No Medical Check up is required if the insured was covered under any Health Insurance Policy of National Insurance Company or other Insurance companies uninterruptedly for preceding three years. Other persons have to undergo medical check up at their own cost for Blood/Urine Sugar, Blood Pressure, Echo-cardiography and eye check up including retinoscopy.

Section I- Hospitalization and Domiciliary Hospitalization Expenses Cover:

1.0  In the event of any claim/s becoming admissible under this section, the Company will pay to the Insured person the amount of such expenses as would fall under different heads mentioned below and as are reasonably and necessarily incurred hereof by or on behalf of such Insured Person but not exceeding the Sum Insured in aggregate mentioned in the Schedule hereto.

1)       Company's overall liability in respect of claims arising due to Cataract is Rs.10,000/- and that of Benign Prostatic Hyperplasia is Rs 20,000/- only.

2) Company's liability in respect of all claims admitted during the period of Insurance shall not exceed the Sum Insured for the person as mentioned in the Schedule.

3)       Liability of the company under Domiciliary Hospitalization clause is limited to 20% of the Sum Insured under Section I and within the overall limit of sum Insured under section I.

4) Hospitalization expenses of person donating an organ during the course of organ transplant will also be payable subject to the sub limits under “C” above applicable to the insured person within the overall sum insured of the insured person.

5) Ambulance charges up to a maximum limit of Rs.Rs.1000/- in a policy year will be reimbursed.

(a)     has been registered either as a Hospital or Nursing Home with the local authorities and is under the supervision of the registered and qualified medical practitioner       OR

(b)  should comply with minimum criteria as under:

i.) It should have at least 15 inpatient beds. In Class "C" towns condition of number of beds may be reduced to10  

ii.)  Fully equipped Operation Theatre of its own wherever surgical operations are carried out

iii.)  Fully qualified nursing staff under its employment round the clock

iv).      Fully qualified Doctor(s) should be in charge round the clock

2.1.1    The term‚ `Hospital/Nursing Home’‚ shall not include an establishment which is a place of rest, a place for the aged, a place for drug addicts or place of alcoholics, a hotel or a similar place.

2.2     Surgical Operation means manual and/or operative procedures for correction of deformities and defects, repair of injuries, diagnosis and cure of diseases, relief of suffering and prolongation of life

2.3    Expenses of Hospitalization for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments i.e. day care treatment for stitching of wound/s, close reduction/s and application of POP casts, Dialysis, Chemotherapy, Radiotherapy, Arthroscopy, Eye surgery, ENT surgery, Laparoscopic surgery, Angiographies, Endoscopies, Lithotripsy (Kidney stone removal), D & C, Tonsillectomy taken in the Hospital / Nursing Home and the Insured is discharged on the same day. The treatment will be considered to be taken under Hospitalization benefit. This condition will also not apply in case of stay in Hospital of less then 24 hours provided –

(a)     the treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in Hospitals.

                           and

(b)     due to technological advances hospitalization is required for less then 24 hours only.

2.4   Domiciliary Hospitalization benefit means medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a Hospital/Nursing Home but actually taken whilst confined at home in India under any of the following circumstances, namely:

i)  The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing Home or

ii) The patient cannot be removed to Hospital/Nursing Home for lack of accommodation therein 

Subject to however that domiciliary hospitalisation benefits shall not cover:

i) Expenses incurred for pre and post hospital treatment and

ii) Expenses incurred for any of the following diseases;

1.       Asthma

2.  Bronchitis

3.  Chronic Nephritis and Nephritic Syndrome

4.  Diarrhea and all type of dysenteries including Gastroenteritis

5.       Diabetes Mellitus and Insipidus

6.       Epilepsy

7.       Hypertension

8.       Influenza, Cough and Cold

9.       All Psychiatric or Psychosomatic Disorders

10.          Pyrexia of unknown Origin for less than 10 days

11.          Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharingitis

12.          Arthritis, Gout and Rheumatism

Note:  When treatment such as Dialysis, Chemotherapy, Radiotherapy is taken in the Hospital/Nursing Home and the Insured is discharged on the same day, the treatment will be considered to be taken under Hospitalization benefit section. Liability of the Company under this clause is restricted as stated in the Schedule attached hereto.

3.0    Any One Illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment may have been taken. Occurrence of same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.

3.1       Pre Hospitalization: Relevant Medical Expenses incurred during period up to 30 days prior to hospitalization/domiciliary hospitalization on disease/illness/injury sustained will be considered as part of claim mentioned under item 1.0 above

3.2     Post Hospitalization: Relevant Medical Expenses incurred up to 60 days after hospitalization/ domiciliary hospitalization on disease/illness/injury sustained will be considered as part of claim mentioned under item 1.0 above

3.3   Medical Practitioner means a person who holds a degree/diploma from a recognised institution and is registered by Medical Council or respective State Council of India. The term Medical Practitioner would include Physician, Specialist and Surgeon.

3.4                Qualified Nurse means a person who holds a certificate of a recognised Nursing Council and who is employed on the recommendations of the attending Medical Practitioner.

3.5                TPA means a Third Party Administrator, who, for the time being, is licensed by the Insurance Regulatory and Development Authority, and is engaged, for a fee or remuneration, by whatever name called as may be specified in the agreement with the Company, for the provision of health services.

3.6       Preexisting Diseases means any ailment/disease/injury that the person is suffering from (known/not known, treated/untreated, declared or not declared in the proposal) whilst taking the policy.

Any complications arising from pre-existing ailment/disease/injury will be considered as Preexisting Diseases.

The Company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any person in connection with or in respect of:

4.1               All diseases/injuries which are pre existing when the cover incepts for the first time. However, those diseases will be covered after one claim free year under this policy. Cost of treatment towards dialysis, chemotherapy & radiotherapy for diseases existing prior to the commencement of this policy is excluded from the scope of cover of this policy even after one claim free year.

            Only two preexisting diseases (Diabetes and/or Hypertension) will be covered    from the inception of the policy provided the company receives additional premium for covering these preexisting diseases and mentions the same in the schedule. . However, any ailment already manifested or being treated and attributable to diabetes and/or hypertension or consequences thereof at the time of inception of insurance will not be covered even on payment of additional premium for covering diabetes and/or hypertension.

4.2               Any disease other than those stated in Clause 4.3, contracted by the Insured Person during the first 30 days from the commencement date of the policy. This condition 4.2 shall not however apply in case of the Insured Person having been covered under this Scheme or group insurance scheme with any one of the Indian Insurance Companies for a continuous period of preceding 12 months without any break.

4.3          During the first one year of the operation of the policy the expenses incurred on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Disease, Fistula in anus, Chronic fissure in anus, Piles, Pilonidal Sinus, Sinusitis, Stone disease of any site, Benign Lumps/growths in any part of the body, CSOM(Chronic Suppurative Otitis Media), joints replacements of any kind unless arising out of accident, surgical treatment of Tonsils, Adenoids and deviated nasal septums and related disorders are not payable. If these diseases (other than Congenital Internal Disease/Defects) are pre-existing at the time of proposal, they will be covered only after one claim free year as mentioned in column 4.1 above. If the Insured is aware of the existence of Congenital Internal Disease/Defect before inception of the policy, the same will be treated as pre-existing.

4.4          Injury or disease directly or indirectly caused by or arising from or attributable to War Invasion Act of Foreign Enemy Warlike operations (whether war be declared or not).

4.5          Vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to as accident or as part of any illness.

4.6          The cost of spectacles and contact lenses, hearing aids.

4.7          Any Dental treatment or surgery which is a corrective, cosmetic or aesthetic procedure, including wear and tear, unless arising from accidental injury and which requires hospitalization for treatment.

4.8          Convalescence, general debility, `Run Down’ condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs / alcohol, rehabilitation therapy in any form.

4.9          All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotrophic Virus Type III (HTLB-III) or Lymphadinopathy Associated Virus  (LAV) or the Mutants Derivative or variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as AIDS.

4.10      Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent with nor incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury for which confinement is required at a Hospital / Nursing Home.

4.11      Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.

4.12      Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.

4.13      Treatment arising from or traceable to pregnancy childbirth including caesarean section.  

4.14      Naturopathy treatment

All claims under this section shall be payable in Indian currency. All medical treatments for the purpose of this insurance will have to be taken in India only.

Sum insured under this section shall be progressively increased by 5 % in respect of each claim free year of insurance subject to maximum accumulation of 10 claim free years of insurance. In case of claim under the policy in respect of insured person who has earned the cumulative bonus, the increased percentage will be reduced by 10% of sum insured at the next renewal. However, basic sum insured will be maintained and will not be reduced.

N.B.: 1) for existing policy holders (as on date of implementation) the accrued amount of benefit of cumulative bonus will be added to the sum insured, subject to maximum 10 claim free years.

          2)  Cumulative Bonus will be lost if policy is not renewed on the date of expiry.

Waiver: In exceptional circumstances where policy is renewed within 7 days from expiry date, the renewal is permissible to be entitled for cumulative bonus although the policy is renewed only subject to Medical Examination and exclusion of diseases developed during the break period .

However, insured has the option either to avail Cumulative Bonus or claim 5% discount in renewal premium will be allowed in respect of each claim free year of insurance subject to maximum of 10 claim free years of insurance. This discount will not be applicable to the S.I. increased if any by the insured at renewal.