MEDICLAIM INSURANCE POLICY (INDIVIDUAL)
1. Salient Features of the policy.
1.1 Individual Mediclaim policy will be available to any individual between the ages of 18 to 80 years for treatment taken in India. An individual can also get his family cover by way family package cover.
DEFINATION OF FAMAILY:
a) Self (Primary Insured)
b) Legal Spouse.
c) Dependent Children (i.e. legitimate or legally adopted children) up to the age of 21 years. If the child above 18 years is employed or if the girl child is married, he or she shall cease to be covered under the policy and no claim shall be admissible. However male child can be covered up to the of 26 years if he is a bonafide regular student and fully dependent primary insured. Female child can be covered until she is unmarried.
d) Dependent parents / parents-in-law.
Family Discount: A discount of 10% in the total premium will be allowed comprising the insured and all his family members mentioned above. (if new member are to be added then new member will be treated under exclusion NO. 4.1, 4.2 and 4.3 as if new policy has been taken for such member.)
Early Entry Discount: If a person taken Mediclaim Policy before reaching the age of 45 years and renews it continuously without break then for each renewal 5% discount subject to maximum of 25% will be given on above revised rates Such years will be counted prior to 45 years of age and such discount will continue for age up to 55 years.
1.2 The Policy reimburses reasonable. customary and necessary expenses of Hospitalization and / or
Domiciliary Hospitalization expenses as detailed below only for illness / diseases contracted or injury sustained by the insured Persons during the policy period up to the limit of Sum insured.
a) Room, Boarding and Nursing Expenses as provided by the Hospital / Nursing Home not exceeding 1% of the sum insured or Rs 5000/- per day whichever is less.
b) I.C Until expenses not exceeding 2% of the Sum Insured or Rs. 10,000/- per day whichever is less. (Room stay including I.C.U stay should not exceed total number of admission days.)
c) Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees.
d) Anaesthesia, Blood, Oxygen, Operation Theater Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical Procedure like pacemaker. Relevant Laboratory / Diagnostics test, X-Ray etc.
e) Ambulance services 1% of the sum insured or Rs. 2000/- whichever is less.
1.3 Cash less Facility: This facility is available in the Network Hospitals through the appointed TPAs of the company a discount of 5% will be given on the scheduled premium if the proposer opts out of the facility.
2.1 HOSPITAL/INSURANCE HOME: means any institution in India established for indoor care and treatment of sickness and injuries and which either
a) Is duly licensed and registered as a Hospital or Nursing Home with the appreciate authorities and is under the supervision of a registered and qualified Medical Practitioner.
b) In areas where licensing and registration facilities with appropriate authorities are not available. The institution must be one recognized in locality as Hospital / Nursing Home and should comply with minimum criteria as under.
i). It should have at least 15 in-patient medicals beds in case of Metro cities, A class cities & B class cities or 10 in-patients medicals beds in case of “C class” cities. Classification of cites shall be as per Govt. of India Notifications issued in this respect from time to time.
ii). Fully equipped Operation Theater 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 physically in-charge round the clock.
The term ‘Hospital / Nursing’ Home shall not be include an establishment which is a place of rest, a place for the aged, a place for drug addicts or a place for alcoholics, a hotel or a similar place
Note: In case of Ayurvedic / Homeopathic / Unani treatment, Hospitalization expenses are admissible only when the treatment is taken as in-patient, in a Government Hospital / Medical Collage Hospital.
2.2 HOSPITALIZATION PERIOD: Expenses on Hospitalization are admissible only if Hospitalization is for a minimum period of 24 hours, except in cases of specialization treatment as detailed here below.
i. Haemo Dialysis,
ii. Parentral Chemotherapy,
iv. Eye Surgery,
v. Lithotripsy (Kidney stone removal),
vii. D & C
viii. Dental surgery following an accident,
x. Coronary Angioplasty,
xi. Coronary Angiography
xii. Surgery of Gall bladder, Pancreas and bile duct
xii. Surgery of Hernia,
xiv. Surgery of Hydrocele,
xv. Surgery of Prostrate,
xvi. Gastrointestinal Surgery,
xvii. Genital Surgery,
xviii. Surgery of Nose,
xix. Surgery of throat,
xx. Surgery of Appendix,
xxi. Surgery of Urinary System,
xxii. Treatment of fractures / disclocation excluding hair line fracture, Contracture releases and minor Reconstructive procedures of limbs which otherwise required hospitalization,
xxiii. Arthroscopic knee surgery,
xxiv. Laproscopic therapeutic surgeries,
xxv. Any surgery under General Anaesthesia,
xxvi. Or any such disease / procedure agreed by TPA / Company before treatment.
Note: PROCEDURES / TREATMENTS USALLY DONE IN OUT PATIENT DEPARTMENT ARE NOT PAYABLE UNDER THE POLITY EVEN IF CONVERTED TO DAY CARE SURGERY / PROCEDURE OR AS IN PATIENT IN THE HOSPITAL FOR MORE THAN 24 HOURS.
2.3 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 as in-patient but actually taken whilst confined at home in India under any of circumstances namely :
i). The Condition of the patient is such that he / she cannot be removed to the Hospital / Nursing Home.
ii). The patient cannot be removed to Hospital / Nursing Home due to lack of accommodation in any Hospital in that city / town / village.
Subject however to the Domiciliary Hospitalization benefit shall not cover
a) Expenses incurred for pre and post hospital treatment and
b) Expenses incurred for treatment for any of the following diseases :
iii. Chronic Nephritis and Nephritis syndrome,
iv. Diarhoea and all types of Dysenteries including Gastro-entritis,
v. Diabetes Mellitus and insipidus,
viii. Influenza, Cough And Cold,
ix. All Psychiatric or Psychosomatic Disorders,
x. Pyrexia of unknown origin for less than 10 days,
xi. Tonsillitis and Upper Respiratory Tract infection including Laryngitis and Pharingitis,
xii. Arthritis, Gout and Rheumatism.
Note: Liability of the Company under this clause restricted as stated in the schedule attached here to.
2.4 INSURED PERSON: means person (s) named on the schedule of the policy.
2.5 ENTIRE CONTRACT: This policy / proposal and declaration given by the insured constitute the complete contract of the policy. Only Insurer may alter the term and conditions of this policy. Any alteration that may be made by the insurer shall only be evidenced by a duly signed and sealed endorsement on the policy.
2.6 NETWORK HOSPITAL: means hospital that has agreed with the TPA to participate for providing cashless health services to the insured person. The list is maintained by and available with the TPA and the same is subject to amendment from time to time.
2.7 PRE-HOSPITALIZATION: Relevant medical expenses incurred for the period upto 30 days prior to hospitalization on disease / illness / injury / sustained will be considered as part of claim mentioned under item 1.2 above.
2.8 POST-HOSPITALIZATIONP: Relevant medical expenses incurred for the period upto 60 days after hospitalization on disease / illness / injury / sustained will be considered as part of claim mentioned under item 1.2 above.
2.9 MEDICAL PRACTITIONER: means a person who holds a degree / diploma of a recognized institution and is registered by Medical Council of any state of India. The term Medical Practitioner would include Physician, Specialist and Surgeon.
2.10 QUALIFIED NURSE: means a person who holds a certificate of a recognized Nursing Council.
2.11 PRE EXISTING HEALTH CONDITION OR DISEASE: means any ailment / disease / injuries that the person suffering from, (treated / untreated, declared or not declared in the proposal from while taking a policy for the first time.
Further any complications arising from pre-existing ailment / disease / injuries will be considered as a part of that pre existing health condition.
2.12 IN-PATIENT: An Insured person who is admitted to hospital and stay for at least 24 hours for sole purpose of receiving the treatment for suffering ailment / illness / disease /injury / accident during the currency of the policy.
2.13 REASONABLE & CUSTOMARY EXPENSES: means reasonable and customary surgical / medical expenses within the scope of treatment of the condition for which the insured person was hospitalized.
2.14 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 & the TPA. In such case 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.
2.15 I.D. CARD: means the card issued to the Insured Person by the TPA to avail Cashless facility in the Network Hospital.
2.16 LIMIT OF INDEMNITY: means the amount stated in the schedule against the name of each insured person which represents maximum liability for any all claim made during the policy period in respect of that insured person for hospitalization taking placed during the currency of the policy.
2.17 ANY ONE ILLNESS: Any one illness will be deemed to mean continues period of illness and it includes relapse within 105 days from the date of discharge from the Hospital / nursing home from where the treatment was taken. Occurrence of the same illness after a lapse of 105 days as stated above will be considered as a fresh illness for the propose of this policy.
2.18 PERIOD OF POLICY: this insurance policy is issued for a period of one year as shown in the schedule.