Star Health Medi Classic Individual Policy-Wording


4.0. CONDITIONS

1. Every notice or communication to be given or made under this policy shall be delivered in writing at the address as shown in the schedule.

2. The premium payable under this policy shall be payable in advance. No receipt of premium shall be valid except on the official form of the company signed by a duly authorized official of the company. The due payment of premium and the observance of fulfillment of the terms, provision, conditions and endorsements of this policy by the Insured Person, in so far as they relate to anything to be done or complied with by the Insured Person, shall be a condition precedent to any liability of the company to make any payment under this policy. NO waiver or any terms, provisions, conditions, and endorsements of this policy shall be valid unless made in writing and signed by an authorized official of the Company.

3. Upon the happening of any event, which may give rise to a claim under this policy, notice with full particulars shall be sent to the Company within24 hours from the date of occurrence of the event.

4. Claim be filed within 15 days from the date of Discharge from the Hospital.

Note: This is a condition precedent to admission of liability under the policy.

5. The Insured Person shall obtain and furnish the Company with all original bills, receipts and other documents upon which a claim a based and shall also give the Company such additional information and assistance as the Company may require in dealing with the claim

6. Any medical practitioner authorized by the Company shall be allowed to examine the Insured Person in case of any alleged injury or diseases requiring Hospitalization when and as often as the same may reasonably be required on behalf of the Company.

7. The company shall not be liable to make any payment under the policy in respect of any claim if such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the Insured Person or by any other person acting on his behalf.

8. If at the time when any claim arises under this policy, there is in existence any other insurance whether it be effected by or on behalf of any Insured Person in respect of whom the claim may have arisen covering the same loss, liability, compensation, costs or expenses, the benefits under this Policy shall be in excess of the benefits available under other insurance/s.

9. Renewal: The Policy may be renewed under mutual consent. The Company shall not however be bound to give notice that it is due for renewal. Where the claims ratio under the insurance for immediately preceding two consecutive periods of Insurance exceeds 100%,the Company may impose a loading of premium as per the scales below:

Average claims ratio between 100-125%-Loading on basic premium 20%

Average claims ratio between 126-150%-Loading on basic premium 30%

Average claims ratio >150%-Loading on basic premium 50% 

However in respect of disease/sickness/illness for which claim/s has/have been made the sum insured will be restricted to that policy sum insured where the claim/s was//were first made.

10. Cancellation: He Company May at any time cancel this policy by sending the Insured 30 days notice by

Registered letter at the insured last known address and in such event the company shall refund to the Insured a pro-rata premium for unexpired period of Insurance the Company shall however remain liable for any claim, which arose prior to the date of cancellation. The insured may at any time cancel this Policy and in such event the Company shall allow refund of Premium a Company’s short period rate only (table given here below) provided no claim has occurred up to the date of cancellation.

PERIOD ON RISK           

RATE OF PREMIUM TO BE CHARGED

Up to one-month 1/3rd of the annual premium
Up to three Month

½ of the annual rate premium

Up to six months

¾th of the annual rate premium

Exceeding six months  

full annual rate premium

5. Automatic Termination: This policy shall terminate immediately on the earlier or the following events:

• Upon the death of the Insured Person in which case the Company will refund premium calculated on pro-rata basic for the unexpired period subject there being no claim under the policy.

• Upon exhaustion of the sum insured

12 Arbitration 

If any dispute or difference shall arise as to the quantum to be paid under this Policy (liability being otherwise admitted) such difference shall independently of all other questions be referred to the decision of a sole arbitrator to be appointed in writing by the parties to the dispute/difference, or if they cannot agree upon a single arbitrator within 30 days of any party invoking arbitration, the same shall be referred to a panel of three arbitrators, comprising of two arbitrators, one to be appointed by each of the parties to the dispute/difference and the third arbitrator to be appointed by such two arbitrators. Arbitration shall be conducted under and in accordance with the provisions of the arbitration and Conciliation Act, 1996.

It is clearly agreed and understood that no difference or dispute shall be referable to arbitration, as hereinbefore provided, if the Company has disputed or not accepted liability under or in respect of this Policy.

It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon this Policy that the award by such arbitrator/arbitrators of the amount of the loss or damage shall be first obtained.

It is also further expressly agreed and declared that if the Company shall disclaim liability to the Insured for any claim hereunder and such claim shall not, within three years from the data of such disclaimer have been made the subject matter of a suit in a Court of Law, then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder.

13 All claims under this policy shall be payable in Indian currency. All medical/Surgical treatments under this policy shall have to be taken in India.

14 No Claim Discount

The Insured Person shall be eligible for No Claim Discount for every claim-free year as per scales below: (not applicable for Family Package Plan)

No of years

Discount on the basic premium

First year

Nil

Beginning of Second year

5%

Beginning of Third year

10%

Beginning of Fourth year

15%

Beginning of Fifth year

20%

Beginning of the Sixth Year and subsequent years

25% (maximum)

 

 

 

 

 

 

 

Note: The No Claim Discount will be allowed only on the Basic premium and on the premium in respect of Add-on covers. Where a claim is made the No claim Discount will scale down one step backward under age group 5 months to 35 years and two steps backward under age group 36 years to 45 years, The No Claim Discount for the age band 46 years to 70 years become NIL when there is a claim Discount will be lost if the policy is not renewed on the date of expiry. In exceptional circumstances 7 days extension in period of renewal is permissible to be entitled for No Claim discount although the policy is renewed only subject to medical examination and exclusion of additional diseases, if any, contracted during such break-in period

15 Package charges The Company’s liability in respect of package charges will be restricted to 80% of such amount. Where package rates are charged the Post-Hospitalization benefit will be calculated after taking the room and boarding charges at Rs.4000 per day. (Package charges refer to charges that are not advertised in the Schedule of the hospital).

16 Relief under Section 80-D: Insured Person is eligible for relief under Section 80-D of the IT Act in respect of the premium paid by way of cheque.

17. Special conditions applicable to Family Package Plan Family means Insured Person, Spouse and dependent children not exceeding 2 numbers the total sum insured is to be equally apportioned all the personscovered. Each family member is covered up-to his/her limit only. No transfer of unutilized balance to other members is permissible. The Insurance with respect each relevant person shall terminate immediately on the earlier of the following events:

  • Upon the death of the Insured Person
  • Upon exhaustion of the sum insured with respect of that person

18 Co-insurance:

  • The Insured person can opt to bear the following in respect of each and every claim:
  • Insured persons in age group 5 months to 35 years: 5% of the claim amount
  • Insured persons in age group 36 years to 45 years: 10% of the claim amount
  • Insured persons in age group 46 years to 70 years: 20% 0f the claim amount
  • Medi-Family Package Plan: NIL
  • In consideration of the co-pay at the specified scale opted by the Insured
  • Perosn discount on the final premium at the following scale is applicable:
  • 4% of the final premium
  • 8% of the final premium
  • 10% of the final premium
  • 12% of the final premium respectively.

19 Policy Disputes Any dispute concerning the interpretation of the terms, conditions, limitations and/or exclusions contained herein is understood and agreed to by both the Insured and the Company to be subject to Indian Law.

20 Notices Any notice, direction or instruction given under this Policy shall be in writing and delivered by hand, post, or facsimile to The Star Health and Allied Insurance Company Limited, No 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai- 600034.

Notice and instructions will be deemed served 7 days after posting or immediately upon receipt in the case of hand delivery, facsimile or e-mail.

21 Customer Service If at any time the Insured Person requires any clarification or assistance, the Insured may contact the offices of the Company at the address specified, during normal business hours

22 Grievances In case the Insured Person is aggrieved in any way, the insured may contact the Company at the specified address, during normal business hours.In the event of the following grievances:

a Any partial or total repudiation of claims by the Company

b Any dispute in regard to premium paid or payable in terms of the policy;

c Any dispute on the legal construction of the policies in so far as such disputes relate to claims;

d Delay in settlement of claims;

e Non-issue of any insurance document to customer after receipt of the premium.

The Insured Person may approach the Insurance Ombudsman, within whose urisdiction the branch or office of Star Health and Allied Insurance Company Limited is located. The Insurance Ombudsman’s offices are locate at Ahmadabad, Bhubaneswar, Bhopal, Chandigarh, Chennai, Gujarat, Kochi, Kolkatta, Lucknow, Hyderabad, Mumbai and delhi.

23 IMPORTANT NOTE: This insurance is available to persons between the ages 5 months and 80 years. Coverage of persons between the age 75 years and 80 years can be considered solely at the discretion of the company.

The Policy Schedule and any Endorsement are to be read together and any word or such meaning wherever it appears.

The Terms conditions and exceptions that appear in the Policy or in any Endorsement are part of the contract and must be complied with. Failure to comply may result in the claim being denied.




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By sandeep bhuse on Jul 18, 2011 8:32 PM

we have more information for individual
Did you know?
Medimanage is the only Dedicated Health Insurance Broker in India.
Medimanage has managed more than 25000 claims end-to-end.
Medimanage insures more than 2 Lakh lives every year.
Testimonials
Just emailing to say thank you to your representative: Soman who never avoided my call or message and was always happy to help me out in all the situation throughout the process of the cashles approval both the time during hospitalization. Thank you soman..:) keep up the good work…
Pratikkumar Upadhyay


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