VARISTHA MEDICLAIM FOR SENIOR CITIZENS
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 Disease covered under Critical illnesses are as under.
Coronary Artery Surgery
Renal Failure i.e. Failure for both Kidneys
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. Person 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.
Pre-acceptance Medical Checkup: No Medical Checkup 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.
Scope of Cover:
Section I- Hospitalization and Domiciliary Hospitalization Expenses Cover:
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 here to.
(i) Room, Boarding expenses as provided by the Hospital/Nursing Home
(ii) If admitted in IC Unit
i) up to 1% of Sum nsured per day
ii) up to 2% of Sum Insured per day overall limit : 25 % of the S.I per illness / injury
Surgeon, Anesthetist Medical practitioner, Consultants specials Fees, Nursing Expenses
|Up to 25 % of Sum Insured per Illness/ Injury
||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 implants.
|Up to 50 % of Sum nsured per Illness/ Injury.
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.1000/- in a policy year will be reimbursed.
2.1 Hospital / Nursing Home, means any institution in India established for indoor care and treatment of sickness and injuries and which
(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” 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.
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 addition or place of alcoholics, a hotel or 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 disease, 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, Angiography, 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 than 24 hours provided-
(a ) the treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in Hospitals.
(b) due to technological advances hospitalization is required for less than 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 hospitalization benefit shall not cover:
i) Expenses incurred for pre and post hospital treatment and
ii) Expenses incurred for any of the following diseases;
3. Chronic Nephritis and Nephritic Syndrome
4. Diarrhea and all type of dysenteries including Gastroenteritis
5. Diabetes Mellitus and Insipidus
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 Pharyngitis
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 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.
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.
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 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 what ever name as may be specified in the agreement with the Company, for the provision of health services