PARIVAR-MEDICLAIM FOR FAMILY
WHEREAS the insured designated in the schedule hereto has by a proposal and declaration dated as stated in the schedule which shall be the basis of this contract and is deemed to be incorporated herein has applied to NATIONAL INSURANCE COMPANY LIMITED (hereinafter called the INSURED PERSON) and has paid premium as considered for such insurance.
NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions contained herein or enclosed, or otherwise expressed here on the company undertakes that if during the period stated in the schedule or during the continuance of this policy by renewal any insured person shall contract any disease or suffer from any illness (hereinafter called DISEASE ) or sustain any bodily injury through accident ( hereinafter called INJURY) and if such disease or injury shall require any such insured person, upon the advice of a duly qualified physician/medical/specialist/medical practitioner (hereinafter called MEDICAL PRACTITINOER) or of a duly qualified Surgeon (hereinafter called SURGEON) to incur hospitalization /domiciliary hospitalization expenses for medical/Surgical treatment at any Nursing Home/Hospital in India as herein defined (hereinafter called HOSPITAL) as an inpatient the company will pay through TPA to the hospital / Nursing Home or the Insured person the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of Insured person but not exceeding the Sum Insured in aggregate in any one period of Insurance stated in the schedule hereto.
SALIENT FEATURES OF THE POLICY:
1.0 In the event of any claim becoming admissible under this scheme, the company will pay to the Insured person the amount of such expenses as would fall under different heads mentioned below, and as are reasonable and necessarily incurred thereof by or on behalf of such Insured person, but not exceeding the Sum Insured in aggregate in any one period of Insurance stated in the schedule hereto.
A. Room, Boarding expenses as provided by the Hospital/Nursing Home limited up to 1% of Sum Insured per day and 2% of Sum Insured per day for ICU/ICCU. Room rent shall include nursing care, RMO charges, IV Fluids, Blood transfusion, Injection, admission charges.
B. Surgeon, Anesthetist Medical practitioner, Consultants specials Fees.
C. Anesthesia, Blood , Oxygen, OT Charges, Surgical appliances (any disposable surgical consumables subject to upper limit of 10% of Sum Insured), Medicines, drugs, Diagnostic Material & X-RAY, Dialysis ,chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs and cost of stent and implant.
Note: (a) Company’s liability would arise if the treatment of disease/injury suffered/contracted is incepted during the policy period. Total expenses incurred for any one illness is limited to 50% of overall Sum Insured per family. Company’s liability in respect of all claim admitted during the period of insurance shall not exceed the Sum Insured mentioned in the Schedule.
(b) Hospitalization expenses of person donating an organ during the course of organ transplant will also be payable subject to the sub limits applicable for any one illness within the overall Sum Insured of the Insured Family.
2.1 Family: Means Self, Spouse and two dependent children (up to an age of 25 years). Parents are not covered. Age limit for insured’s 3 months to 60 years
2.2 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
(b) Should comply with minimum criteria as under:
i. It should have at least 15 inpatient beds. In class “C” town’s 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.
2.2.1 The term, Hospital/ Nursing Home shall not include an establishment which is a place of for the rest, a place for the aged, a place for drug addiction or place of alcoholics, a hotel or similar place.
2.3 Surgical Operation means manual and/or operative procedures for correction of deformities and defects, repair of injuries, diagnosis and cure of disease, relief of suffering and prolongation of life.
2.4 Expenses of Hospitalization for minimum period of 24 hours are admissible. However this time limit is not applied to specific treatments i.e. Dialysis, Parentral Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (kidney stone removal), D & C Tonsillectomy Dental Surgery due to accident, Hysterectomy, coronary Angioplasty, coronary Angiography, Surgery of Prostate, Gastrointestinal Surgery ,Genital Surgery ,Surgery of Nose, Surgery of Throat, Surgery of Appendix, Surgery of Urinary System, Arthroscopic Knee Surgery, Laparoscopic Therapeutic Surgeries, Any Surgery under Anesthesia, Treatment of Fractures/Dislocation excluding hairline fracture, Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalization taken in the Hospital/Nursing Home under the network of TPA and the Insured is discharged on het same day. The treatment will be considered under Hospitalization Benefit.
Relaxation to 24 hours minimum duration for hospitalization is also applicable:
(A) If they are carried out in day care center networked by the TPAs where requirement of minimum number of beds is overlooked but it must have
(i) Fully equipped Operation Theatre
(ii) Fully qualified Day care staff
(iii) Fully qualified Surgeons/Post Operative attending Doctors.
(B) If it necessitates hospitalization and involves specialized infrastructural facilities available only in hospital but due to technological advancement hospitalization is required for less than 24 hours and/or the surgical procedure involved has to be done under General Anesthesia.
3.0 Any One Illness will be deemed to mean continuous period of the illness for which treatment is undergone and includes relapse within 105 days from the date of last consultation with the Hospital/Nursing Home where treatment was taken. Occurrence of same illness after a lapse of 105 days 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 15 days prior to hospitalization/domiciliary hospitalization on disease/illness/injury sustained will be considered as a part of claim under the item 1.0 above.
3.2 Post-Hospitalization: Relevant Medical Expenses incurred during period up to 30 days after hospitalization/domiciliary hospitalization on disease/illness/injury sustained will be considered as a part of claim under the item 1.0 above.
3.3 Medical Practitioner means a person who holds a degree/diploma as a recognized institution and is registered by Medical Council or respective State 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 recognized Nursing Council and is who is employed on recommendations of the attending Medical Practitioner.
3.5 Pre-existing 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 out of the pre-existing ailment/disease/injury will be considered as pre-existing disease.
3.6 TPA means a Third Party Administrator who is licensed by the Insurance Regulatory and Development Authority, and is engaged for a fee or remuneration, by whatever name as may be specified in the agreement with the Company, for the provision of health services.
3.7 ID Card means the card issued to the insured person by the TPA to avail cashless facility in the network hospitals.
3.8 Network Hospital means hospital that has agreed with the TPA to participate for providing cashless health services to the insured persons. The list is to be maintained by the TPA and is subject to amendment from time to time.
3.9 Cashless Facility means the TPA may authorize upon the insured’s request for direct settlement of admissible claim as per agreed charges between Network Hospitals and the TPA. In such cases the TPA will directly settle all eligible amounts with the network hospitals and the insured person may not have to pay any bills after the end of the treatment at hospital to the extent the claim is covered under the policy.
3.10 In-patient: An insured person who is admitted to hospital and stays for at least 24 hours for the sole purpose of receiving the treatment for suffered ailment/illness/disease/injury/accident during the currency of the policy.
3.11 Hospitalization Period: The period for which an Insured person is admitted in the hospital as inpatient and stays there for the sole purpose of receiving necessary and reasonable treatment for the disease/ailment/injury sustained during the period of policy. The minimum period of stay shall be 24 hours.
3.12 Reasonable and Customary Expenses: means reasonable and customary surgical/medical treatment expenses within scope of cover of this policy to treat the condition for which the insured person was hospitalized.
3.13 Limit of Indemnity: means the amount stated in the schedule against the name of each insured person which represents maximum liability for any and all claims made during the policy period in respect of that insured person with regard to hospitalization taking place during currency of the policy.
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 four continuous claim free policy years. For the purpose of applying this condition, the period of covered under mediclaim policy taken from National Insurance Company only will be considered.
4.1.1 Insured shall bear 10% of any admissible claim if he is suffering from either diabetes or hypertension and 25% of the admissible claim amount in case he is suffering from both diabetes and hypertension. This provision is applicable only to the claims arising out of Diabetes and Hypertension.
However pre-existing diseases arising due to hypertension and diabetes can be covered with an additional premium-10% for hypertension or diabetes, 25% for hypertension and diabetes both.
4.2 Any disease other than those stated in clause 4.3, contracted by the Insured person during the first thirty 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 our company for a continuous period of preceding 12 months without any break or is hospitalized due to accidental injuries suffered after inception of the policy.