New India Individual Mediclaim Policy-Wording


Individual Mediclaim Policy

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 THE NEW INDIA ASSURANCE COMPANY LTD (hereinafter called the COMPANY) for the Insurance hereinafter set forth in respect of person(s) named in the schedule hereto (hereinafter called the INSURED) and has paid premium as consideration for such insurance.

1.0 Coverage NOW THIS POLICY WITNESS that subject to the terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed hereon, the Company undertakes that if during the period stated in the Schedule 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 Surgeon (hereinafter called SURGEON) to incur Hospitalization Expenses (herein defined) for medical/Surgical treatment at Nursing Home/Hospital in India as herein defined (hereinafter called HOSPITAL/NURSING HOME /DAY-CARE CENTRE) as an inpatient, the Company /Third party administrator will pay to the hospital / Nursing home/Day Care Centre or reimburse the insured person the following expenses that are necessarily incurred in the treatment of such disease or injury.

2.0 Following reasonable, customary & necessary expenses are reimbursable under the policy:

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2.1 Room, boarding and nursing expenses as provided by the hospital/nursing home not exceeding 1% of the sum insured (excluding cumulative bonus) per day or actual amount whichever is less.

2.2 Intensive Care Unit (ICU) /Intensive Cardiac Care Unit (ICCU) expenses not exceeding 2.0% of the sum insured (excluding cumulative bonus) per day or actual amount whichever is less.

2.3 Surgeon, Anesthetist, Medical Practitioner, Consultants Specialist Fees.

2.4 Anesthesia, Blood, Oxygen, Operation Theatre charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, artificial limbs, cost of Prosthetic devices implanted during surgical procedure like pacemaker, Relevant Laboratory/ Diagnostic test, X-Ray and other medical expenses related to the treatment.

2.5 Pre-hospitalization medical charges up to 30 days period immediately before the insured admission to hospital for that illness or injury.

2.6 Post hospitalization medical charges up to 60 days period immediately after the Insured discharge from the hospital for that illness of injury. 

Note: 1. The amounts payable under 2.3 and 2.4 shall be at the rate applicable to the entitled room category. Incase insured opts for a room with rent higher than the entitled category as under 2.1, the charges payable under 2.3 and 2.4 shall be limited to he charges applicable to the entitled category. 

2.7 Expenses incurred for Ayurvedic / Homeopathic/ UNANI Treatment are admissible up to 25 % of the sum insured provided the treatment is taken in a Government Hospital.

2.8 Ambulance services- actual expenses or maximum of Rs 1,000/-whichever is less in case patient has to be shifted from residence to hospital or from accidental spot to the hospital for admission in Emergency Ward or ICU or from one Hospital/Nursing Home to another Hospital/Nursing Home by fully equipped ambulance for better medical facilities.

2.9 Hospitalization expenses payable (excluding cost of organ) incurred on the donor during the course of organ transplant to the insured person. The Company’s liability towards expenses incurred on the donor and the insured recipient shall not exceed the sum insured set for the insured person, receiving the organ.

2.10 (a) Persons paying Zone I premium can avail treatment in any Zone. The maximum liability of the Company will be 100% of the Sum Insured.

(b) Persons paying Zone II premium

(i) Availing treatment in Zone II and Zone III, the company’s liability will be 100% of the sum insured.

(ii) Availing treatment in Zone I will bear 10% of each claim. The maximum liability of the company will not exceed 90% of the sum insured.

(c) Person paying Zone III premium

(i) Availing treatment in Zone III, the company’s liability will be 100% of the sum insured.

(ii) Availing treatment in Zone II will bear 10% of each claim. The maximum liability of the company will not exceed 90% of the sum insured.

(iii) Availing treatment in Zone I will have to bear 20% of each claim. The maximum liability of the Company will not exceed 80% of the sum Insured

3.0 DEFINITIONS:

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3.1 PRE-EXISTING CONDITION means any sickness/illness, which existed prior to the effective date of this insurance, whether or not the insured person had knowledge that symptoms were related to the sickness/illness. Complication arising from a pre- existing condition will also be considered as a part of that pre- existing condition.                                        

3.2 HOSPITAL/NURSING HOME means any institution in India established for indoor care and treatment of sickness and injuries and which has been registered either as a hospital or Nursing home with the local authorities and is under the supervision of registered and qualified medical practitioner.

Or

Complies with the minimum criteria as under:

(a) Must have a minimum of:

10 in-patient beds if located in towns having population of less than 10 lacs.

Or

15 In-patient beds if located in other towns.

(b) Fully equipped operation theatre of its own wherever surgical operations are carried out.

(c) Fully qualified Nursing staff under its employment round the clock.

(d) Fully qualified Medical Practitioner should be in- charge round the clock.

(e) Maintains daily medical record for each of its patients.

Note: In case of Ayurvedic /Homeopathic / Unani Treatment (b) is not applicable

In case of Day Care Centre (a) is not applicable

For the purpose of this definition the term Hospital/Nursing Home/Day Care Centre shall not include an establishment, which is a place for the aged, a place for drug addicts of place for alcoholics, a hotel or any other like place.

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3.3 SURGICAL OPERATION means manual and/or operative procedures for correction of deformities/defects, repair of injuries, cure of diseases, and relief of suffering and prolongation of life.

3.4 HOSPITALIZATION means admission in any Hospital /Nursing Home in India upon the written advice of a medical practitioner for a minimum period of 24 consecutive hours.

The time limit of 24 hours will not be applicable for following surgeries / procedures.

ANTI Rabies Vaccination

Hysterectomy

Appendectomy

Inguinal/Ventral/Umbilical/Femoral Hernia repair

Coronary Angiography

Lithotripsy (Kidney Stone Removal)

Coronary Angiography

Parenteral Chemotherapy

Dental Surgery following an accident

Piles / Fistula

Dilatation & Curettage (D & c) of Cervix

Prostate

Eye Surgery

Radiotherapy

Fracture/dislocation excluding hairline
fracture

Sinusitis

Gastrointestinal Tract system

Stone in Gall Bladder, Pancreas, and Bile Duct

Haemo- Dialysis

Tonsillectomy

Hydrocele

Urinary Tract System

OR any other Surgeries/ Procedures agreed by TPA/COMPANY which require less than 24 hours hospitalization due to subsequent advancement in medical Technology.

3.5 ANY ONE ILLNESS will be deemed to mean continuous period of the illness for which treatment is undergone and includes relapse within 45days from the date of last consultation with the Hospital/Nursing Home where treatment was taken. Occurrence of same illness after a lapse of 45 days stated above will be considered as fresh illness.

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3.6 MEDICAL PRACTITIONER means a person who holds a degree/ diploma of a recognized institution and is registered by Medical council of respective State of India. The term Medical Practitioner would include physician specialist and surgeon and shall not include INSURED person and members of his family covered under this insurance.

3.7 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.

3.8 THIRD PARTY ADMINISTRATOR (TPA) means a third party administrator as mentioned in the policy schedule, licensed by the Insurance Regulatory and Development Authority (IRDA) and agreed by the COMPANY for a fee or a remuneration for providing cashless facility and or reimbursement of claim to insured person under the policy.

3.9 NETWORK HOSPITAL means the Hospital, Nursing Home, Day Care Center, or such other medical aid provider that has agreed with the TPA to participate for providing cashless facility to policyholder’s .Non-network provider shall mean any other Hospital/Nursing Home/Day Care Center, or such other Medical Aid provider, who has not agreed to provide such cashless facility.

3.10 CASHLESS FACILITY means facility whereby the TPA agrees on the insured request, to settle the admissible claim directly to the network hospital .Any expenses in excess of the admissible claim amount will, however, be borne by the insured himself.

3.11 ID CARD means the Identity Card issued to the insured person by the TPA to avail cashless facility network hospitals

3.12 DAY CARE PROCEDURE means the course of medical treatment/Surgical Procedure in specialized Day Care Center which enables the insured to be discharged on the same day.

3.13 CUSTOMARY AND REASONABLE CHARGES means and the charges for health care, which is consistent with the prevailing rate in an area or charged in a certain geographical area for identical or similar services.

4.0 EXCLUSIONS:

The company shall not be liable to make any payment under this policy in respect of:

4.1 Pre-existing Diseases/condition: All diseases /injuries/conditions, which are pre-existing when the cover incepts for the first time (except as shown hereunder) any complication arising from Preexisting disease/ailment/injury will be considered as a part of pre-existing condition. This exclusion will be deleted after four consecutive claim free policy year provided there was no hospitalization for the pre-existing disease/aliment/condition/injury during the said four years of insurance with our company.

Compulsory Coverage for Specific Pre-Existing Conditions:

On payment of additional premium, which is compulsory for person suffering from the pre-existing conditions of Diabetes mellitus and Hypertension these specific pre-existing conditions only are covered in the following manner.

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1st year

No Claim

2nd

year

No Claim

3rd year

50% of admissible claim or 50 % of the sum insured set for the individual
whichever is less

4th year

75% of admissible claim or 75 % of the sum insured set for the individual
whichever is less

5th year
onwards

100 % of admissible claim or sum insured set for the individual whichever is less.

4.2 30- day Exclusion : Any disease other than those stated in clause 4.3 below contracted by the insured person during first 30 days from the commencement date of the policy is excluded. This exclusion will not apply if the policy is renewed with our company without any break. The exclusion does not also apply to treatment for accidental injuries.

4.3 Waiting period for specified diseases/aliments/conditions:

From the time of inception of the cover, the policy not covers the following diseases/aliments/conditions for the duration shown below. This exclusion will be deleted after the duration shown, provided the policy has been continuously renewed with our Company without any break.

Sr.No

Name of Disease/Aliment/Surgery not covered for

Duration

1

Any skin Disorder

Two Years

2

All internal & external benign tumors, cysts, polyps of any kind including
benign breast lumps

Two Years

3

Benign Ear, Nose, Throat, disorders

Two Year

4

Benign Prostate Hypertophy

Two Years

5

Cataract & age related eye aliments

Two Years

6

Diabetes mellitus

Two Years

7

Gastric / Duodenal Ulcer

Two Years

8

Gout & Rheumatism

Two Years

9

Hernia of all types

Two Years

10

Hydrocele

Two Years

11

Hypertension

Two Years

12

Hysterectomy for Manorrhagia / Fibromyoma, Myomectomy and
Prolapse of Uterus

Two Years

13

Non Infective Arthritis

Two Years

14

Piles, Fissure and Fistula in Anus

Two Years

15

Pilonidal Sinus, Sinusitis and related disorders

Two Years

16

Prolapsed Inter Vertebral Disc unless arising from accident

Two Years

17

Stones in Gail Bladder & Bile duct

Two Years

18

Stones in Urinary Systems

Two Years

19

Unknown Congenital internal disease/ defects

Two Years

20

Varicose Veins and Varicose Ulcers

Two Years

21

Age related Osteoarthritis & Osteoporosis

Four Years

22

Joint Replacements due to Degenerative condition

Four Years

4.4 Permanent Exclusions: Any medical expenses incurred for or arising out of:

4.4.1 War, Invasion, Act of foreign enemy, War like operations, Nuclear weapons, lonising Radiation, Contamination by Radioactive material nuclear fuel or nuclear waste.

4.4.2 Circumcision, cosmetic or aesthetic treatment, plastic surgery unless required to treat any injury or illness.

4.4.3 Vaccination & Inoculation

4.4.4 Cost of braces, equipment or external prosthetic devices, non – durable implant, eyeglasses, Cost of spectacles and contact lenses, hearing aids including cochlear implants and durable medical equipments.

4.4.5 All types of Dental treatments except arising out of an accident.

4.4.6 Convalescence, general debility , Run –down condition or rest cure, obesity treatment and its complications, congenital external disease / defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, use of intoxicating drugs/alcohol, use of tobacco leading to cancer.

4.4.7 Bodily injury or sickness due to willful or deliberate exposure to danger (except in an attempt to save a human life) intentional self- inflicted injury, attempted suicide and arising out of no adherence to any medical advice.

4.4.8 Treatment of any Bodily injury sustained whilst or as a result of active participation in hazardous sports of any kind

4.4.9 Treatment of any Bodily injury sustained whilst or as a result of participating in any criminal act.

4.4.10 Sexually transmitted diseases, any condition directly or indirectly caused due to or associated with Human T- Cell Lymphotropic Virus Type III (HTLB-III) or Lymphotropathy Associated Virus (LAV OR THE Mutants Derivative or variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS.

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4.4.11 Diagnostics, X-Ray OR Laboratory examination not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/ Nursing Home.

4.4.12 Vitamins and tonics unless forming part of treatment of injury or disease as certified by the attending physician.

 


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By a.k.anandi on Jul 13, 2014 2:07 PM

overian cyst removal is covered under the scheme or not-with pol. age-1yr 9month
By Harin Munshi on Oct 25, 2013 11:15 AM

If sleep apnea is diagnosed and bariatric surgery is strongly advised, whether expenses for such claims are reimbursable?
By deepak yadav on May 14, 2013 5:57 PM

I have already exisiting 5lacs mdeicalim policy of new india assurance co. and I want to buy ore 10lacs medicalim policy of same comapnies i.e. new india assurance co. I want know there is any limit for individuals for mediclaim/
By Mahesh on Apr 26, 2011 10:10 PM

I request every human being to think and study the exclusion of the policy before taking the policy, as i think this kind of policy with huge premium and huge number of exclusion is of no use for a middle class person.
By K G SHETTY on Sep 20, 2010 3:22 PM

STOP CHEATING PUBLIC. CLAIMS ARE DEDUCTED AT MOST 35 % BY HOOK-OR-KROOK STATING ANY CLAUSES, CHANGES ANY TIME WITHOUT ANY ADVERTIEMENTS IN ANY NEWS PAPERS OR INTIMATIONS TO PATIENTS / POLICY HOLDERS.
By rajeev on Sep 9, 2010 2:26 PM

What does it mean by---Note: 1. The amounts payable under 2.3 and 2.4 shall be at the rate applicable to the entitled room category. Incase insured opts for a room with rent higher than the entitled category as under 2.1, the charges payable under 2.3 and 2.4 shall be limited to he charges applicable to the entitled category. Do you mean--an Insured will get 1% or 2 % of amount spent on 2.3 & 2.4 ( say if if the Charges are Rs.2 lacs--you pay Rs.2000 or Rs.4000 only?
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Medimanage has managed more than 25000 claims end-to-end.
Medimanage insures more than 2 Lakh lives every year.
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I Would like to say thanks to all who helped me to reimburse the medical claim .For taking so much initiative and the efforts once again thanking you all.
Venkatesan.P


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