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a. Scope Of Cover
1) Room, Boarding expenses as provided by the Hospital/Nursing Home.
2) Nursing expenses.
3) Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees.
4)Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical appliances(any disposable consumables subject to upper limit of 10% of Sum Insured), Medicines & Drugs, Diagnostic Materials and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker, Artificial Limbs and cost of Stents and implants
Note: Hospitalization expenses of person donating an organ during the course of organ transplant will also be payable subject to the sub limits under “4” above applicable to the insured person within the overall sum insured of the insured person.
b. Other benefits
1. The guardian of the insured will be eligible for deduction under Section 80 D of the Income Tax Act 1961 as amended from time to time, for the premium paid under this section of the policy subject to limits specified in the Income Tax Act.
2.The Policy will be serviced by Third Party Administrators (TPA) for hospitalization expenses.
3. Cumulative Bonus
Sum insured under this policy 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.:
a) for existing Mediclaim policy holders (as on date of implementation) of the company the accrued amount of benefit of cumulative bonus will be added to the sum insured, subject to maximum 10 claim free years.
b) Cumulative Bonus will be lost if policy is not renewed on the date of expiry.
However, insured has the option either to avail cumulative bonus or claim 5% discount in renewal premium 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.
c. Definitions
1.Hospital/Nursing Home means any institution in India established for indoor care and treatment of sickness and injuries and which either
(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 to 10.
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
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.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.
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.
4.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.
5. Pre Hospitalisation: Relevant Medical Expenses incurred during period up to 30 days prior to hospitalisation on disease/illness/injury sustained will be considered as part of claim mentioned under item 1.0 above
6.Post Hospitalisation: Relevant Medical Expenses incurred up to 60 days after hospitalisation/ domiciliary hospitalisation on disease/illness/injury sustained will be considered as part of claim mentioned under item 1.0 above
7.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.
8.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.
9.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.
Exclusions:
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 :
1. All diseases/injuries, which are pre-existing when the cover incepts for the first time. This exclusion will be deleted after three continuous claims free years under this policy.
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 any health insurance scheme with any one of the Indian Insurance Companies for a continuous period of preceding 12 months without any break.
3. During the first 2 years 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 four continuous claim free years 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. 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).
5. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, 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 an accident or as part of any illness.
6. The cost of spectacles and contact lenses hearing aids.
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.
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.
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.
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.
11. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.
12. Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.
13. Treatment arising from or traceable to pregnancy childbirth including caesarean section.
14. Naturopathy treatment |
