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Cholamandalam Family Health Insurance Policy-Wording


Chola Family Health Insurance Policy Wording

INDEX

Introduction                        1

Index                                   2


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Coverage Parts                    3

Definitions                           6

General Exclusions              10

General Conditions              13

Day Care Procedure             18

Schedule of Benefits             23

COVERAGE PARTS

The insurer’s agreement to extend cover to the insured up to the limit of indemnity per the terms and conditions in this policy is based upon the Proposer’s payment of premium and the proposal, which is incorporated into the policy and is the basis of it.

Certain words or expressions have the specific meaning given in Section B whenever they appear in bold and in Initial Capitals in this policy.

A Coverage Parts

1) Upon the happening of the event under a) to e) and g) below during the Policy Period, the Insurer will indemnify the Proposer up to the Limit of Indemnity as detailed below and as per the General Conditions:

a) Hospitalization Expenses

If the insured is diagnosed with an illness or suffers Accidental Bodily Injury, Which necessitates Hospitalization Expenses for:

i) Room and board

ii) Doctors fees

iii) Intensive Care Unit

iv) Nursing expenses

v) Surgical fees, operating theatre, anesthesia and oxygen and their administration

vi) Physical therapy

vii) Drugs and medicines consumed on the premises

viii) Costs of prosthetic devices if implanted during a surgical procedure

ix) Organ transplantation including the treatment costs of the donor but excluding the costs of the organ

b) Post-hospitalization Expenses

If the insurer accepts a claim under a) above and, immediately following the insured’s discharge, he requires further medical treatment directly related to the same condition for which the insured was Hospitalized, the insurer will reimburse the insured’s Post-hospitalization Expenses for up to 90 days following his discharge. 

C) Pre-hospitalization Expenses

It the Insured is diagnosed with an illness which results in his Hospitalization and for which the Insurer accepts a claim under a) above, the Insurer will reimburse the Insured’s Pre-hospitalization Expenses for up to 60 days prior to his Hospitalization as long as the 60 day period commences and ends within the Policy Period.

Specific Conditions Applicable to a) – c) inclusive:

i) The Administrator will arrange for cash free payment to the extent of the insurer’s liability for Hospitalization Expenses incurred at Network Hospitals subject to the Insured’s satisfaction of General Conditions D4) and 6).

ii) If the Insured for any reason chooses not to use a network Hospital or otherwise breaches the terms of the authorization obtained pursuant to General Condition 4) c),then the amount payable by or on behalf of the Insurer shall be reduced as per the co-payment table and shall be borne by the Insured. This clause shall not apply if due to an illness or Accidental Bodily Injury an Insured requires Emergency Hospitalization or change of Hospital so as to avoid a material risk to the Insured’s life or health, and as a result the Insured is unable to obtain pre-authorization provided that: 

(1) The Administrator is given notice of the Insured’s Hospitalization as soon as reasonably practicable, and

(2) The terms of General Condition D4) are complied with as soon as the material risk to the Insured’s life or health has passed.

d) Day Care Expenses

If the Insured requires a Day Care Procedure, the Insurer will reimburse the Day Care Expenses as long as the Day Care Procedure performed was pre-authorized by the Administrator and done at a network hospital.

e) Local Ambulance Services

The Insurer will also pay for Emergency ambulance road transportation by a Incensed ambulance service to the nearest Hospital where Emergency Health Services can be rendered. Coverage is only provided in the event of an Emergency up to the limits given in Schedule of Benefits.

f) Hospital Daily Allowance

The Insurer will also pay for the Hospital Daily Allowance benefit per day of Hospitalization in India for a limited period per family and policy period. The limits under this section are provided in Schedule of Benefits. Benefits under this section are subject to the hospitalization claim being admitted by the Company under Coverage Parts A1a).

G) External Aids and Appliances

If the Insurer accepts a claim under a) above and, immediately following the Insured’s discharge, he requires further External Aida and Appliances directly related to the same condition for which the Insured was Hospitalization, the Insurer will reimburse the Insured’s External Aids and Appliances expenses up to the limits given in Schedule of Benefits. Benefits under this section are subject to the hospitalization claim being admitted by the Company under Coverage Parts A1a). This benefit covers following External Aids and Appliances only

i) Abdominal belts (used Post-Hernia and related surgeries)

ii) Belts for prolapsed Inter-vertebral disc (PIVD)

iii) Artificial Limbs

iv) Crutches

v) Wheel-chair

vi) Trusses (used Post-Hernia and related surgeries) 

h) Home Nursing Care Allowance

The Insurer will also pay for the Home Nursing Care Allowance per day for a limited period per family and policy period towards the nursing expenses incurred post-hospitalization, provided that the Treating Registered Medical Practitioner recommends such care in view of medical condition of the Insured immediately following discharge from the Nursing Care Services. Coverage is only provided up to the limits given in Schedule of Benefits. Benefits under this section are subject to the hospitalization claim being admitted by the Company under Coverage Parts A1a).

DEFINITIONS

B Definitions

For ease of reference, the singular includes the plural and the male gender includes the female gender where appropriate to the context. Accidental Bodily Injury means physical bodily harm or injury that is visible and is caused by a sudden, unexpected, fortuitous, visible and external event and which requires treatment by a Doctor. Administrator means the person or organization named in the Schedule who has been appointed by the Insurer to provide administrative services on its behalf of and at its directions.

Cash Free payment means the Administrator may authorize upon an Insured’s request for direct settlement of eligible services and its according charges between a Network Hospital and the Administrator. In such cases the Administrator will directly settle all eligible amounts with the Network Hospital and the Insured may not have to pay any deposits at the commencement of the treatment or bills after the end of treatment to the extent as these services are covered under the Policy.

Co-Payment Table means the table attached to the Schedule.

Day Care Expenses means the medical treatment costs (nursing; Doctors; medically necessary procedures and medical consumables) necessary and reasonable in scope for a Day Care Procedure pre-authorized by the Administrator & done in a network Hospital to the extent that such cost does not exceed the reasonable and customary charges applicable in the locality for the same Day Care Procedure.

Day Care Procedure means the course of medical treatment or a surgical procedure listed in the Schedule, which is undertaken under general or local anesthesia in a Hospital by a Doctor in not less than 2 hours and not more than 24 hours. This excludes all procedures or treatment taken in the Out Patients Department.

Doctor means a person who holds a medical degree from a recognized institution and is currently licensed or registered by the Medical Council of the respective State of India, so long as he acts within the scope of the license or registration granted to him.

Emergency means a serious medical condition or symptom resulting from injury or Sickness, which arises suddenly and requires immediate care and treatment to avoid jeopardy to the life or serious damage to the health of the Insured. The emergency continues till the condition of the Insured stabilizes and the continuing medical condition or symptoms are not considered an Emergency anymore.

Home Nursing Care: Services provided a Registered Nurse, which are directed toward the personal care of the Insured; provided that the Treating Registered Medical Practitioner recommends such care in view of medical condition of the Insured immediately following discharge from the Hospital bed.

Hospitalization or Hospitalized means the Insured’s admission for a continuous period of not less than 24hours into a Hospital, which means an institution in India, which:

a) Is properly licensed, and in areas where licensing facilities are unavailable, the institution must be one recognized in the locality as a Hospital and must satisfy b) to d)below inclusive;

b) Is primarily engaged in providing diagnostic, medical and surgical facilities for the care and treatment of injured or sick persons on an inpatient basis, and is not an institutions which is primarily a rest or convalescent facility, a place for custodial care, a facility for the aged or alcoholics or drug addicts or for the treatment of mental disorders;

c) Employs Doctors and qualified nursing staff who are permanently available on the premises to provide necessary medical care and attention to patients on a 24-hours basis;

d) Maintains daily medical records for each of its patients.

Hospitalization Expenses means the medical treatment costs and:

a) For a Network Hospital shall mean the rates pre-agreed between the Network Hospital and the Administrator which relate to medical treatment that is necessary and reasonable in scope to treat the condition for which the insured was Hospitalized;

b) For any other Hospital shall mean the cost of medical treatment that is necessary and reasonable in scope to treat the condition for which the Insured was Hospitalized to the extent that such cost does not exceed the reasonable and customary charges that Hospitals in the same locality would have charged for the same medical treatment.

Identification or ID card means the card issued to the Insured by the Administrator. Illness means condition affection the general well being and health of the body or an affection of the bodily organs having a defined and recognized pattern of symptoms that first manifests itself in the Policy Period and which requires treatment by Doctor. It does not mean any mental illness (a mental or bodily condition marked primarily by sufficient disorganization of personality, mind, and emotions to seriously impair the normal psychological, social, or work performance of the individual) regardless of its cause or origin.

Insured means:

a) The Persons named in the Schedule.

b) The Proposer’s:

i) Legal spouse;

ii) Children aged between 90 days and 19 years at the commencement of the Policy Period if they are unmarried, still dependant on the Proposer and have not established their own independent households;

iii) Unmarried dependent children aged between 20 and 26 years at the commencement of the Policy Period if in full or part time education and primary dependent upon the Proposer for financial support and maintenance;

iv) Any other person who during the Policy Period falls within one of the foregoing categories as long as the details of such person are notified to the Insurer within 3 months of the entitlement having arisen; any documentation or information sought by the Insurer has been provided expeditiously; the Insurer has agreed to the extension of cover, and any additional premium sought by the Insurer has been paid.

Insurer means the Cholamandalam MS General Insurance Company Limited.

Floater means the Limit of Indemnity floats over the Insured and the declared Dependents as per the policy schedule.

Limit of Indemnity means the amount stated in the Schedule against the name of Insured and including the declared Dependents as appearing in the policy schedule. It represents the maximum liability of the Insurer for any and all claims made during the Policy Period in respect of that Insured and his declared Dependents regardless of the number of Coverage Parts under which the claim or claims are advanced.

Network Hospital means the institutions named on a list maintained by and available from the Administrator, as the same may be amended from time to time.

Policy means the proposal, this policy document and the Schedule, which means the schedule attached as the insurer may amend it from time to time.

Policy Period means the period between the effective date and the earlier of:

a) The expiry date specified in the Schedule, and

b) The exhaustion of the Limit of Indemnity for particular Insured as regards that Insured, and

c) The cancellation of this Policy by either Insured or Insurer in accordance with General Condition D 8) below.

Pre-Existing Condition means any Injury or Sickness and/or related conditions for which the Insured received medical advice or treatment, or to the best of his knowledge and belief was aware existed during the 24 months period prior to the Effective Date of the first individual health policy with the Insurer.

Pre-hospitalization Expenses and Post-hospitalization Expenses means the medical treatment cost (Doctor’s services; diagnostics; medically necessary procedures and medical consumables) necessary and reasonable in scope to treat the condition for which the Insured is to be or was Hospitalized to the extent that such cost not exceed the reasonable and customary charges that hospitals in the same locality would have charged for the same medical treatment.

Proposer means the person named in the Schedule.

Registered Nurse means a graduate nurse who has been registered or licensed by a recognized Nursing Council (in India) or equivalent authority to discharge duty as a nurse.

Room Rent means the daily limit specified in the Schedule payable towards the occupancy of the room in the hospital. The room rent is inclusive of the articles of use but excluding telephone expenses.

Schedule means the Schedule of Benefits which is attached and which form a part of this Policy.


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By Tarak Dey on Dec 29, 2010 12:00 PM

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